2013

The ABCs of ECGs

A collection of notes from audio recordings,

videos, lectures and workshops

Maryam Fareed Ashoor

Royal College of Surgeons in
Ireland – Bahrain
A key to remembering is understanding. Never try to
memorize something without knowing what it means. It
won’t work, I’ve tried it.
 Introduction to the heart:
The heart is an important organ in the human body. It carries out the main function as we all
know of pumping blood through the body. For the heart to be able to pump it needs the
contraction of the heart muscles (ie. Myocardia). For the myocardia to contract it needs a
signal, this is carried out by a special system known as the pacemaker and the conduction
pathway of the heart. This conduction system carries the electrical signals that lead to the
contraction of the heart muscles and subsequently the pumping of the blood through the
system. Imagine the heart as a light bulb, and the pacemaker as the switch, and the conduction
pathway as the connecting wire. For the heart to contract you need the pacemaker to start and
the conduction pathway to carry that signal.

Conduction
pathway

Pacemaker

Heart
muscle

The blood supply to the heart:

The heart is supplied by 2 main arteries; these are known as coronary arteries. You get the right
coronary artery and the left coronary artery which then divides into the left anterior
descending artery and the left circumflex artery.

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You need to know which area each artery supplies; this will greatly help you later on when
reading an ECG. No need to memorize this, just picture the heart and you will easily tell which
artery supplies where.

Right coronary artery: the inferior surface of the heart

Left anterior descending artery: the anterior surface of the heart

Left circumflex artery: the lateral surface of the heart

What is an ECG?

This is an ECG:

ECG is short for ElectroCardioGram. Electro- meaning electrical activity, Cardio- meaning the
heart, and Gram meaning a graph or a diagram. So it basically means a graph that shows the
electrical activity of the heart. This is a very easy yet important concept to keep in mind.
Whenever you have an ECG paper in your hand then you have a record of the electrical activity,
not the structure, and not the pumping function of the heart. Hold that thought.

Why ECG?
An ECG is an important diagnostic tool, which you will encounter as a medical student and as a
doctor. It can tell you a lot just by a quick look at it. Any disease which affects the electrical
conduction in the heart can be mostly seen and diagnosed with an ECG. It’s fast, cheap and

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reliable. What you need to know is that there’s no short cut to reading an ECG. A shortcut will
only be seen once you have practiced and read many ECGs throughout the years. But there’s an
easy way for reading an ECG. Despite what everyone else might try to convince you about how
hard it is to learn ECG, I’m only writing this to share with you how easy it can be if you are
willing to learn.

When do we use ECGs?

You will use an ECG when suspecting an abnormality with the heart, this includes arrhythmias,
Myocardial Infarctions mostly. You can also use it to exclude a cardiac cause for a symptom
such as with syncope. It’s handy to remember these as if you were ever asked to list your
management for a patient with those conditions you can always start by saying ECG.

How to use an ECG?

The ECG that you are required to know is the paper which has the waves, and how to read that.
However it’s only when you learn how that paper is produced using the machine that you will
come to find ECG extremely easy. So let’s start step by step.

James, a 44 years old comes to clinic with chest pain on exertion that has been increasing.
After taking the history you decide to have an ECG done.

1- For the ECG to read the electrical activity of the heart you need to place 12 leads on the
body. You can think of these leads as the connection points for the circuit of electrical
activity to be read by the machine.

12 leads :

- 6 pericardial leads: placed on the chest

- 3 limb leads: placed on the arms and left leg
- 3 augmented limb leads: the same 3 limb leads but will read in different directions.

This is James with the leads

attached.

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 A closer look to understand where each lead is positioned:
Chest leads:

Limb leads: (note where the + is, that’s the side it will be reading)

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 Now you can easily understand which area will each lead read based on its location.

Let’s have a look:

Lead 1: will read from the left = lateral surface of the heart.
Lead 2: will read from the bottom= inferior surface of the heart.
Lead 3: will read from the bottom= inferior surface of the heart.
Lead aVF: at the foot= inferior surface of the heart
Lead aVR: at the right arm= often neglected. Because it reads the right side.
Lead aVL: at the left arm= lateral surface of the heart
Lead v1, v2, v3, v4: anterior surface of the heart
Lead v5&v6: lateral surface of the heart

Now take your time in knowing these. Whenever you are comfortable with that, you are
ready to master ECG interpretation. Because simply if you look at any ECG paper now
and see an abnormality on lead v5, v6 and aVL you will easily say that something is
wrong with the lateral side of the heart! As simple as that. Or if you see an abnormality
in lead aVF, and you want to make sure something is affecting the inferior surface of the
heart, you can go simply and look at lead 2 and 3 to make sure because they all read the
inferior surface of the heart!
Keep going over this list to learn the grouping of leads because this is essential yet easy
for making a diagnosis.

And here’s a useful term: contiguous leads: any two leads which read the same area on
the heart.
List of contiguous leads:
Lead 1, aVL, v5, v6: lateral surface
Lead 2, 3, aVF: inferior surface
Lead v1,v2,v3,v4: anterior surface

ECG waves:
Now that you have learned how to position the different leads and what each means,
we can start looking at the ECG paper itself and interpret it.
Here’s a normal single cardiac cycle on the ECG:

Large box Small box

P wave:
QRS complex:
Depolarization
Depolarization
of the atria T wave:
Isoelectric of the ventricles
line Repolarization of
the ventricles
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 Here’s a useful piece of information, a wave can be either positive or negative. To explain this,
have a look at this ECG:

Downward = negative wave

Upright =
positive
wave

If it was pointing upward (like the waves in lead 2 for example), then it’s a positive wave.
(**Extra information: Whenever the wave is positive, this means the electrical impulse is
moving toward the lead, so in lead 2, it means the impulse is moving toward lead 2 which is
located on the foot. This makes sense because you will expect the impulse to run from the atria
to the ventricles below it). If the wave is pointing downwards (like the waves in lead aVR), this
means the electrical impulse is moving away from the lead (again, this makes sense because the
impulse will move toward the left as the heart is positioned that way, and so aVR will always be
negative on an ECG because the impulses shouldn’t move toward the right side).

A simple diagram showing how the impulses are normally expected to move:

The heart

The body

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How to read an ECG?
Now that you know what each lead represents, and so you can make sense of the different
numbers and letters on the ECG paper, you can now easily go through the steps of reading an
ECG. The good news is, you have already done the “hard part” of knowing the leads, all that is
yet to come is just simply building up on that.

Whenever a doctor hands you an ECG whether it was in a ward or as a question in the exam, all
you have to do is go through the following checklist one by one and you will end up reading
every detail on that paper in no time and impressing the doctor with how good you are!

What does an ECG paper have?

Each ECG paper will have waves recorded from all the 12 leads previously mentioned. As you
can see I have circled each lead to point them out for you, the name of each lead will be the
upper left corner. This is how you should look at each ECG paper you get. Because a change in
one lead doesn’t mean a change in all of them, so you will need to go through them one by one.
But what about that red box surrounding a continuous long pattern at the bottom of the ECG
paper? Well, this is usually lead 2 being displayed for 10 seconds on the ECG paper. You will use
this for counting the rate, especially when it’s irregular (see later).

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ECG checklist:
This is a checklist; the most important thing with it is to follow it by order, DO NOT skip steps.
Even if you saw an ECG and immediately knew the diagnosis, you have to go through these in
order not to miss anything, and any doctor will be expecting you to tell him these when he asks
you about an ECG.

The first 4 are the easiest and the most important to start with:

1- Details:

The first thing to do when given an ECG paper is to read the details of the patient. The name
of the patient, the age and the chief complaint if provided. This will extremely guide you
toward what you are looking for before even looking at the ECG. In an exam, this is usually
provided in the question stem which tells you the history of the patient. Based on that, you
will be suspecting to see something specific on the ECG. For example, a patient with a left
sided heavy chest pain radiating to his left arm, associated with nausea will get you to
suspect an MI, and there for you will look for the features on an MI on the ECG paper.

2- Rate:

Counting the rate of the heart is the first thing you will do after going through the details.
Measuring the rate is very simple, you have two types of rates. Look at the ECG paper you
have, more specifically look at the long strip at the bottom of the paper because that is
continuous (refer to the ECG paper in page 8).

Ask yourself: are the spaces between the Q waves equal throughout the paper or not?

1) If yes: regular rate = 300/number of large boxes between any 2 Q waves.

In this case: 300/4 (number of small boxes) = 75 BPM

2) If no: irregular rate= number of QRS complexes in a whole strip * 6.

Example: as you can see in the strip below, the number of small boxes varies between the
QRS waves. Some have 3, some have 4 and some have 2 in between. So this is an irregular
rhythm. So we will use the second rule by counting the number of QRS complexes along the
strip and multiplying that by 6 (because the strip represents 10 seconds).

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 14* 6 = 84 BPM

Any rate between 60 – 100 BPM is normal.

3- Rhythm

The rhythm describes the regularity of electrical activity. The normal rhythm is said to be
“Sinus” (ie. Generating from the sinus node).

For a rhythm to be sinus:

- Each P wave is followed by a QRS complex

- R R intervals are constant (it basically means the spaces between the QRS complexes are
constant, which gives regular rhythm)
- Check lead 2, P wave is upright

Abnormal rhythms (arrhythmias) will be discussed later.

4- Axis

Axis simply describes the position of the heart in the chest cavity. Sometimes the heart might
pathologically deviate to the right or left. Or physiologically deviate to the left (like in
pregnancy). The axis is a vector, this means you need to look at 2 values to come up with it.

You will learn now how to do that in 2 easy steps,

For measuring the axis, you need to remember two main rules that you have already learned:

- Lead 1 reads the lateral (left) side of the heart, lead aVF reads the inferior surface of the
heart
- If a wave is positive, the signal is moving toward the lead. So if lead 1 was positive, you
will automatically know that the signal is moving toward the left. If lead aVF is positive,
the signal is moving toward the inferior.

These two rules will be essential in recognizing the axis of the heart anytime you get an ECG
paper.

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To help you with that, draw a circle
-90
(imagine the circle as the body):

1- Now draw a line that represents aVF

(which goes vertically from up to
down) and one that represents lead 0
180 Lead 1
1 (which goes horizontally from right
to left). The arrow is positioned
where the signal normally moves to
make it easier for you.
2- Add the degrees around the circle 90
like you learned to do in school in aVF
math. (0, 90, 180)

Why do we need these numbers and values?

Because with them you can tell what the axis is and determine if it’s normal or deviated.
Normal axis: 0-90
Left axis deviation: -90 – 0
Right axis deviation: 90 – 180

So if we fill in the circle with the information, it will look like this:
-90

Left axis
deviation
180 0
Lead 1
Right axis Normal
deviation axis

90
aVF

(Some might wonder about the area between 180 - -90, that’s called No-Man’s land. The
axis can’t fall in that range. If you calculate it and it does, go over what you did, there’s
probably a mistake somewhere.)

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 Now let’s get you an ECG paper and see how we can apply the circle in learning the axis:

From the circle you will remember that the two leads we are concerned about are lead 1
and aVF only. (Because these run vertically and horizontally across the body)
1- Look at lead 1: is the QRS wave positive? (ie. Upright)
Yes, then the signal is moving toward the lead = toward the left.
Color the left side of your circle.

-90

Left axis
deviation
180 0
Lead 1
Right axis Normal
deviation axis

90
aVF

2- Look at lead aVF: is the QRS wave positive? (ie. Upright )

Yes, then the signal is moving toward aVF = inferiorly.

Color the inferior side of your circle.

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 -90

Left axis
deviation
180 0
Lead 1
Right axis Normal
deviation axis

90
aVF

Simply look at your circle, in which side does the two colors meet?

Between (0-90)

0-90 = normal axis

That’s it.

With time and practice you will be able to draw that circle and get the axis within seconds in
your head!

Here’s another example on the axis:

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Let’s go through the same 2 steps:

1- Look at lead 1: is the QRS wave positive? (ie. Upright)

Yes, then the signal is moving toward the lead = toward the left.
Color the left side of your circle.
-90

Left axis
deviation
180 0
Lead 1
Right axis Normal
deviation axis

90
aVF

2- Look at lead aVF: is the QRS wave positive? (ie. Upright )

No, then the signal is moving away from aVF = upwards.

Color the upward side of your circle.

-90

Left axis
deviation
180 0
Lead 1
Right axis Normal
deviation axis

90
aVF

Simply look at your circle, in which side does the two colors meet?

Between (-90 - 0)

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-90 - 0 = left axis deviation

That’s it.

This way you can tell any axis at any ECG, and with practice you won’t even need to draw the
circle.

(Small hint: right axis deviation is always pathological, but left axis deviation can be
physiological or pathological. To differentiate between the two, after getting the axis have a
look at lead 2, if it was +, then it’s a physiological left axis deviation. If it was -, then it’s a
pathological left axis deviation. If you look at this ECG above, you will notice that lead 2 is
negative, so it’s a pathological left axis deviation)

After these main 4 headlines (details, rate, rhythm, axis), if you can tell these by looking at
any ECG, then you are on the right track. Take your time practicing. Google ECG samples and
try describing the previous 4 stems we have just been through.

Once you are comfortable, you can move to the next points in the checklist.

5- Intervals and segments:

An interval is the time taken between two waves, on an ECG paper it’s simply the number
of boxes between two waves.

- PR interval: 3- 5 small boxes is normal (additional information: remember that PR is the

time between the atrial contraction –P wave- and the ventricular contraction –QRS
complex-, if it was taking more than 5 small boxes it indicates a delay in the
communication between the atria and ventricles. So you will suspect a block in the AV

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 node which connects the atria and ventricles, if it was taking less you will suspect WPW
syndrome where you get an abnormal faster pathway than the normal)
- QRS interval: 3 small boxes or less is normal. This is the width of the QRS complex.
- QT interval: this depends on the heart rate. Normally it’s 9-11 small boxes.

A segment is a part of the ECG line which normally passes on the isoelectric line.

Here you are not concerned with the width of this segment but rather with the position of it
above or below the isoelectric line. And essential segment that you should know is the ST
segment, which if elevated would indicate a STMI (ST elevated myocardial infarction), but if
depressed might indicate an angina or NSTEMI (non ST elevated myocardial infaction)

How to identify an MI:

A myocardial infarction is one of the most important indications for ECG, whenever you get a
patient who you suspect is having an MI you will order an ECG to be done. It’s crucial for
making a diagnosis. To identify an MI on an ECG you need to identify an ST elevation (above the
isoelectric line) in at least 2 contiguous leads (previously discussed). This makes sense, because
if you have an infarct at the lateral surface of the heart, then you would expect to see an ST
elevation in aVL, lead 1, V5 and V6 since all of these are reading the same area of the heart (the
lateral surface). There’s no point of diagnosing a person with a heart attack if the elevation was
in one isolated lead only, you need logically at least 2 leads to confirm your diagnosis. This is
why it was essential for you to learn which leads read the same area in the beginning, now this
should be very easy for you.

So for you to accurately diagnose an MI using an ECG, you need to remember 2 rules that you
have previously learned:

1- The contiguous leads list:

Lead 1, aVL, v5, v6: lateral surface
Lead 2, 3, aVF: inferior surface
Lead v1,v2,v3,v4: anterior surface
2- The blood supply to each area:
Right coronary artery: inferior surface (lead 2, 3 and aVF)
Left descending coronary artery: Anterior surface of the heart (v1, v2, v3, v4)
Left circumflex artery: lateral surface (lead 1, aVL, v5 and v6)

By only these 2 simple rules you will see how you will spot diagnose an MI with just one look at
the ECG.

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Let’s look at this ECG:

Let’s say you have gone through your checklist, now you have reached point number 5
(intervals and segments). You are looking at the ST segment in each lead separately. You will
notice just like I did that it looks like there’s an ST elevation above the isoelectric line in lead v1
(red dot). But how can you be sure?

That’s easy, just go back and look at the contiguous leads to v1. You now know that v1 goes
with v2, v3, v4 in reading the anterior surface of the heart. So let’s look at their ST segments
(blue dots). You will notice that there’s an ST elevation as well! This means you have an anterior
wall myocardial infarction correctly diagnosed by just looking at the ECG.

Here’s a harder question to test your knowledge, which artery is blocked in that patient?

Hmm, let’s think. The MI is affecting the anterior wall. Which artery supplies the anterior wall?

It’s the left anterior descending artery! That’s it. As simple as that. It just needs a little bit of
practice.

(Remember; ALWAYS look at contiguous leads together. Don’t look at a single isolated lead)

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Advanced ECG:
This part is advanced and aims to make some sense of the different types of arrhythmias, if you
wish to go through it make sure you have had a grasp of the previous points in this booklet.

Arrhythmias:

An arrhythmia is any abnormal rhythm in the heart. The rhythm describes the generation and
propagation of the electrical impulse in the heart. The pacemaker of the heart is the sinus node
(SA node), which is where the normal rhythm should generate and then spread through the
conducting system as shown in the picture in order:

SA node: (the pacemaker and generator of rhythm) – AV node: (the connection between the
atria and ventricles) – bundle of His – left and right bundle branches: (spreads through the
ventricles).

However, all the muscle cells in the heart have the ability to generate an impulse if something
wrong occurred at the conduction system. For example, normally the impulse will generate at
the SA node and then move along to the AV node to reach the ventricles. But if the AV node
was blocked, then the ventricles won’t just stop, instead they will start generating their own
impulse, because their cells have the capacity to do so but didn’t need it before. This will
produce an abnormal rhythm on the ECG which is one of many types of arrhythmias. This is just
a brief introduction to try and explain what an arrhythmia is.

Here are some useful terms:

Sinus rhythm: a sinus rhythm is that produced at the sinus node (the pacemaker of the heart).

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If an impulse is produced at any other site, it’s called an ectopic impulse and that site is called
an ectopic foci.

Re-entry: if the impulse after being generated goes back through an abnormal connection to
the site which was already depolarized (hence the name, it re- enters an area which was
passed)

Point of re-entry, the impulse keeps

going back like its running in circles
due to abnormal conduction.

For a normal rhythm, you need a normal formation of the impulse and then a normal
conduction system to carry it. Therefore arrhythmias will occur due to a problem in of these.

Classification of arrhythmias based on the mechanism of occurrence:

1- Problem at impulse formation:

A. Alteration at SA node activity:
The impulse is still generating at the SA node, but it’s either too fast (more than 100
BPM) giving rise to Tachycardia, or too slow (less than 60 PBM) giving rise to a
Bradycardia.
B. Ectopic foci:
This is where you get a cell which normally doesn’t generate an impulse forming an
impulse and taking over the SA node as the pacemaker. This ectopic focus can be any
cell at any site of the heart, and according to that you get all the different types of
arrhythmias, so let’s have a look:
- Atrial flutter:

This occurs due to re-entry, the impulse goes back through an abnormal conduction pathway
and tries to depolarize the atrium which has already been depolarized. As a result instead of a

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full atrial contraction you get flutters only. The characteristic “saw tooth” appearance on the
ECG (you won’t miss this! Labeled in blue) which replace the normal P waves.

- Atrial Fibrillation:

This is the MOST COMMON arrhythmia you will encounter. A fibrillation indicates having
multiple ectopic foci firing, none which is sufficient to cause contraction of the atria, so you
get a chaos wave activity instead of P waves. (No atrial contraction = No P waves). You can
see that on the diagram above, many sites in the atria are firing instead of normally just the
SA node.

- Ventricular Fibrillation:

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This is FATAL if not dealt with immediately. If you understood Atrial fibrillation, this is the
exact same concept but in the ventricles. You get multiple ectopic foci firing at the ventricle,
non which is sufficient to cause ventricular contraction, so you get chaotic waves instead of
the QRS complexes. (Note in the diagram of the heart how many foci at the ventricles are
firing.)

Here’s a Question that you may ask: why is ventricular fibrillation fatal and atrial fibrillation
isn’t?

Because in atrial fibrillation, the atria won’t contract

and pump to the ventricles. This is fine because most
of the blood (about 75%) goes to the ventricles
directly from the atria before contraction by gravity
and opened valves and so on. So even if your atria
aren’t contracting you still get most of the blood to
the ventricles. However, if your ventricles aren’t
pumping because they are fibrillated then you will
get no blood going to the whole body! Because all
the blood exits the ventricles into the aorta only
when the ventricles actively contract (remember the
shape of the heart).

2- Problem at impulse conduction:

A. A new pathway of conduction:

For example in WPW (Wolff Parkinson White syndrome), you get a congenital problem
with a new pathway called the
bundle of Kent which is a
connection between the atria
and the ventricles that
bypasses the AV node. This
pathway is faster than the
normal pathway through the
AV node.

B. A block in the
conduction pathway:

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 This is a block at any site of the conduction pathway. The main impulse is still generating
at the SA node, but there’s a block along the way which prevents it from reaching all the
heart chambers. A block can either be at the AV node level, or later on at the bundle
branches:
- AV block
1) 1st degree block: all impulses pass through the AV node, but slower. So you get
greater delay between the P waves and the QRS complexes (greater PR interval).
2) 2nd degree block: some impulses will pass while others won’t. So you will get P
waves followed by QRS complexes with increasing delay until you miss one QRS
complex.
3) 3rd degree block: also known as complete heart block. No impulses pass, the atria
and the ventricles will beat independently. (the SA will depolarize the atria, but the
ventricles will develop their own pacemaker since they are not getting any from the
blocked AV node)

Longer PR interval

Missed QRS Conducted QRS

P waves and QRS

complexes are
independent

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 - Bundle branch block:
A block can be either at the left or right bundle branches. The way I preferred in learning
how to differentiate between these on ECG is (William and Marrow). Remember these
two names as I will be explaining how to use them. These two names carry all the
mnemonics and hints you need to remember how to recognize bundle branch blocks.

First let us agree on which leads we will be looking at. You need to look at a lead which
reads left and one which leads right. So you will look at v1, and v6.

1) Right bundle branch block RBBB: remember Marrow

maRRow has 2 R letters in the middle, so it will be used for RBBB. Makes sense? R goes
for right.
MarroW starts with an M and ends with a W. so you will look for an M on v1 and a W on
v6! If you have that, it’s a RBBB.

Have a look:

Directly go to v1 and v6, v1 has an M

and v6 has a W. so it’s Marrow. Which
means Right bundle branch block!

2) Left bundle branch block LBBB: remember William

wiLLiam has 2 L letters in the middle, so it will be used for LBBB.

WilliaM starts with a W and ends with an M. so you will look for a W in v1 and an M in v6! If you
have that, it’s a LBBB.

Have a look:

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Directly go to v1 and v6, v1 has a W and v6 has an M. so it’s William. Which means Left
bundle branch block!

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There’s so much more to ECG than what is mentioned in here, but this carries the
essential basics which should get you through making sense of what ECG is all about.
I hope this booklet was somehow useful to you. This is purely my personal notes aided
by diagrams from Google images. Therefore, it might carry a number of mistakes and
faults. If you have come across any, do not hesitate to report them to me so that I can
correct them.

For inquires and reporting mistakes:

Email MariamFareed@hotmail.com
Twitter account: @MariamFareed

Kind Regards,
Maryam Fareed Ashoor, Medical student at RCSI – Bahrain.

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