Confirm Details

 Confirm the name and date of birth of the patient matches the

details on the ECG.
 Check the date and time the ECG was performed.

Step 1 – Heart Rate

What’s a normal adult heart rate?

 Normal – 60-100 bpm

 Tachycardia > 100 bpm
 Bradycardia < 60 bpm

Regular Heart Rhythm

If a patient has a regular heart rhythm their heart rate can be calculated

using the following method:

 Count the number of large squares present within one R-R interval
 Divide 300 by this number to calculate the heart rate

Example
 4 large squares in an R-R interval
 300/4 = 75 beats per minute

 
 Ho
w to calculate a heart rate on a normal ECG

Irregular Heart Rhythm

If a patient’s heart rhythm is irregular the first method of heart rate

calculation doesn’t work (as the R-R interval differs significantly throughout
the ECG). As a result, you need to apply a different method such as:

 Count the number of complexes on the rhythm strip (each rhythm strip
is typically 10 seconds long)
 Multiply the number of complexes by 6 (giving you the average
number of complexes in 1 minute)

Example
 10 complexes on a rhythm strip
 10 x 6 = 60 beats per minute

Step 2 – Heart rhythm

 A patient’s heart rhythm can be regular or irregular.

Irregular rhythms can be either:

 Regularly irregular (i.e. a recurrent pattern of irregularity)

 Irregularly irregular (i.e. completely disorganised)

Mark out several consecutive R-R intervals on a piece of paper, then move
them along the rhythm strip to check if the subsequent intervals are similar.

Hint
If you are suspicious that there is some atrioventricular block (AV block),
map out the atrial rate and the ventricular rhythm separately (i.e. mark
the P waves and R waves). As you move along the rhythm strip, you can then
see if the PR interval changes, if QRS complexes are missing or if there
is complete dissociation between the two.

Me
asure the R-R intervals to assess if the rhythm is regular or irregular 1

Step 3 – Cardiac axis

 Cardiac axis describes the overall direction of electrical spread within
the heart.
 In a healthy individual, the axis should spread from 11 o’clock to 5
o’clock.
 To determine the cardiac axis you need to look at leads I, II and III.
 To get a better understanding of cardiac axis read our guide.

Normal cardiac axis

Typical ECG findings for normal cardiac axis:

 Lead II has the most positive deflection compared to Leads I and III

No
rmal cardiac axis

Right axis deviation

Typical ECG findings for right axis deviation:

 Lead III has the most positive deflection and Lead I should

be negative
 Right axis deviation is associated with right ventricular hypertrophy

Rig
2
ht axis deviation 

Left axis deviation

Typical ECG findings for left axis deviation:

 Lead I has the most positive deflection

 Leads II and III are negative
 Left axis deviation is associated with heart conduction abnormalities.
 Lef
t axis deviation 2

Step 4 – P waves
The next step is to look at the P waves and answer the following
questions:

 Are P waves present?

 If so, is each P wave followed by a QRS complex?
 Do the P waves look normal (check duration, direction and shape)?
 If  P waves are absent, is there any atrial activity?
 Sawtooth baseline → flutter waves
 Chaotic baseline → fibrillation waves
 Flat line → no atrial activity at all

Hint
If P waves are absent and there is an irregular rhythm it may suggest a
diagnosis of atrial fibrillation.
 P
waves 1
 

Step 5 – PR interval  

 The PR interval should be between 120-200 ms (3-5 small squares)

Prolonged PR Interval (>0.2 seconds)

 A prolonged PR interval suggests the presence of atrioventricular delay

(AV block)

First-degree heart block (AV block)

 First-degree heart block involves a fixed prolonged PR
interval (>200 ms)
 Fir
st-degree heart block (AV block)

Second-degree heart block (Mobitz type 1 AV

block or Wenckeback phenomenon)
 Second-degree AV block (type 1) is also known as Mobitz type 1
AV block or Wenckebach phenomenon.
 Typical ECG findings in Mobitz type 1 AV block include progressive
prolongation of the PR interval until eventually the atrial impulse is not
conducted and the QRS complex is dropped.
 AV nodal conduction resumes with the next beat and the sequence of
progressive PR interval prolongation and the eventual dropping of a QRS
complex repeats itself.
 Sec
ond-degree AV block (Mobitz Type 1 – Wenckebach)

Second-degree heart block (Mobitz type 2 AV block)

 Second-degree AV block (type 2) is also known as Mobitz type 2
AV block.
 Typical ECG findings in Mobitz type 2 AV block include a consistent
PR interval duration with intermittently dropped QRS
complexes due to a failure of conduction.
 The intermittent dropping of the QRS complexes typically follows
a repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P wave.
 Sec
ond-degree AV block (Mobitz type 2 AV block) 3

Third-degree heart block (complete heart block)

 Third-degree (complete) AV block occurs when there is no
electrical communication between the atria and ventricles due to a
complete failure of conduction.
 Typical ECG findings include the presence of P waves and QRS
complexes that have no association with each other, due to the atria
and ventricles functioning independently.
 Cardiac function is maintained by
a junctional or ventricular pacemaker.
 Narrow-complex escape rhythms (QRS complexes of <0.12
seconds duration) originate above the bifurcation of the bundle of His.
 Broad-complex escape rhythms (QRS complexes >0.12 seconds
duration) originate from below the bifurcation of the bundle of His.
 Co
mplete heart block (3rd degree) 4

Tips for remembering types of heart block

To help remember these degrees of AV block, it is useful to remember the
anatomical location of the block in the conducting system:

 First-degree AV block:
 Occurs between the SA node and the AV node (i.e. within the
atrium)

 Second-degree AV block:
 Mobitz I AV block (Wenckebach) – occurs IN the AV node (this is
the only piece of conductive tissue in the heart which exhibits the ability
to conduct at different speeds)
 Mobitz II AV block – occurs AFTER the AV node in the bundle of
His or Purkinje fibres

 Third-degree AV block:
 Occurs anywhere from the AV node down causing complete
blockage of conduction

Shortened PR Interval
 If the PR interval is shortened, this can mean one of two things:

 Simply, the P-wave is originating from somewhere closer to the AV

node so the conduction takes less time (the SA node is not in a fixed place
and some people’s atria are smaller than others).
 The atrial impulse is getting to the ventricle by
a faster shortcut instead of conducting slowly across the atrial wall. This
is an accessory pathway and can be associated with a delta wave (see
below which demonstrates an ECG of a patient with Wolff Parkinson White
syndrome).

Del
ta wave 5

Step 6 – QRS complex

When assessing a QRS complex, you need to pay attention to the
following characteristics:

 Width
 Height
 Morphology
 Var
ious components of an ECG

Width

Width can be described as NARROW (< 0.12 seconds) or BROAD (> 0.12

seconds)

 A narrow QRS complex occurs when the impulse is conducted down

the bundle of His and the Purkinje fibre to the ventricles. This results in
well organised synchronised ventricular depolarisation.
 A broad QRS complex occurs if there is an abnormal depolarisation
sequence – for example, a ventricular ectopic where the impulse spreads
slowly across the myocardium from the focus in the ventricle. In contrast,
an atrial ectopic would result in a narrow QRS complex because it would
conduct down the normal conduction system of the heart. Similarly, a
bundle branch block results in a broad QRS complex because the impulse
gets to one ventricle rapidly down the intrinsic conduction system then has
to spread slowly across the myocardium to the other ventricle.

Height

Describe this as SMALL or TALL:

 Small complexes are defined as < 5mm in the limb leads or < 10 mm
in the chest leads.
 Tall complexes imply ventricular hypertrophy (although can be due to
body habitus e.g. tall slim people). There are numerous algorithms for
measuring LVH, such as the Sokolow-Lyon index or the Cornell index.

Morphology

To assess morphology, you need to assess the individual waves of the QRS
complex.

Delta wave
 The mythical ‘delta wave’ is a sign that the ventricles are being
activated earlier than normal from a point distant to the AV node. The
early activation then spreads slowly across the myocardium causing the
slurred upstroke of the QRS complex.
 Note – the presence of a delta wave does NOT diagnose Wolff-
Parkinson-White syndrome. This requires evidence of tachyarrhythmias
AND a delta wave.

Del
5
ta wave 
 Q-waves
 Isolated Q waves can be normal.
 A pathological Q wave is > 25% the size of the R wave that follows it or
> 2mm in height and > 40ms in width.
 A single Q wave is not a cause for concern – look for Q waves in an
entire territory (e.g. anterior/inferior) for evidence of previous myocardial
infarction.

Q
waves (V2-V4), with T wave inversion suggestive of previous anterior MI 6
 

R and S waves
 Look for R wave progression across the chest leads (from small in V1 to
large in V6).
 The transition from S > R wave to R > S wave should occur in V3 or
V4.
 Poor progression (i.e. S > R through to leads V5 and V6) can be a sign
of previous MI but can also occur in very large people due to poor lead
position.

 
 Po
or R wave progression 7

J point segment
 The J point is where the S wave joins the ST segment
 This point can be elevated resulting in the ST segment that follows it
also being raised (this is known as “High take-off”)
 High take-off (or benign early repolarisation to give its full title) is a
normal variant that causes a lot of angst and confusion as it LOOKS like ST
elevation

Key points for assessing the J point segment:

 Benign early repolarisation occurs mostly under the age of 50 (over the
age of 50, ischaemia is more common and should be suspected first)
 Typically, the J point is raised with widespread ST elevation in multiple
territories making ischaemia less likely
 The T waves are also raised (in contrast to a STEMI where the T wave
remains the same size and the ST segment is raised)
 The ECG changes do not change! During a STEMI, the changes will
evolve – in benign early repolarisation, they will remain the same.
 Step 7 – ST segment
 The ST segment is the part of the ECG between the end of the S wave
and the start of the T wave.
 In a healthy individual, it should be an isoelectric line (neither elevated
or depressed).
 Abnormalities of the ST segment should be investigated to rule out
pathology.

Var
ious components of an ECG

ST-elevation

 ST-elevation is significant when it is greater than 1 mm (1 small

square) in 2 or more contiguous limb leads or >2mm in 2 or more
chest leads.
 It is most commonly caused by acute full-thickness myocardial
infarction.
 ST
elevation in the anterior leads
 

ST depression

 ST depression ≥ 0.5 mm in ≥ 2 contiguous leads indicates

myocardial ischaemia.
 ST
depression
 

Step 8 – T waves
 T waves represent repolarisation of the ventricles.

Tall T waves

T waves are considered tall if they are:

 > 5mm in the limb leads AND

 > 10mm in the chest leads (the same criteria as ‘small’ QRS
complexes)

Tall T waves can be associated with:

 Hyperkalaemia (“Tall tented T waves”)

 Hyperacute STEMI

Tal
8
l tented T waves 

Inverted T waves

 T waves are normally inverted in V1 and inversion in lead III is a normal

variant.
 Inverted T waves in other leads are a nonspecific sign of a wide variety
of conditions:
 Ischaemia
 Bundle branch blocks (V4 – 6 in LBBB and V1 – V3 in RBBB)
 Pulmonary embolism
 Left ventricular hypertrophy (in the lateral leads)
 Hypertrophic cardiomyopathy (widespread)
 General illness
 Around 50% of patients admitted to ITU have some evidence of T wave
inversion during their stay.
 Observe the distribution of the T wave inversion (e.g.
anterior/lateral/posterior leads).
 You must take this ECG finding and apply it in the context of your
patient.
 Inv
erted T wave
 

Biphasic T waves

 Biphasic T waves have two peaks and can be indicative of ischaemia

and hypokalaemia.
 Flattened T waves

 Flattened T waves are a non-specific sign, that may represent

ischaemia or electrolyte imbalance.

Fla
ttened T wave 9
 U waves
 U waves are not a common finding.
 The U wave is a > 0.5mm deflection after the T wave best seen
in V2 or V3.
 These become larger the slower the bradycardia – classically U waves
are seen in various electrolyte imbalances, hypothermia and secondary to
antiarrhythmic therapy (such as digoxin, procainamide or amiodarone).

U wave 10

Document your
interpretation
You should document your interpretation of the ECG in the patient’s notes
(check out our guide to documenting an ECG here).