Department III, Discipline of Physiology

Electrocardiography
ECG Interpretation

2020 -2021 Ş.l.Dr. Daciana Nistor

As. Univ. Dr. Nilima Kundnani
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 Contents

1. INTERPRETATION OF ELECTROCARDIOGRAM (ECG)

1.1. Determining the cardiac rhythm
1.2. Calculating the heart rate (HR)
1) Direct Method – with the help of formula
2) Indirect Method (approximate value) – rapid method
1.3. Determining the electrical axis of the heart
1) Using Einthoven triangle
2) Using the rapid method with the help of quadrants
3) Using the rapid method with help of maximum and
minimum projections
1.4. Morphological and chronological analysis of the ECG trace
2. Practical exercises
3. Clinical application
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4. MCQ’s
 OBJECTIVES

The student must know:

1. To determine if there is a sinus rhythm or not on the ECG
2. To determine the HR by 2 methods:
1) Direct method- by using the formula
2) Indirect method (approximate value) – by using rapid method
3. To determine the electrical axis of the heart by three methods
1) With the Einthoven triangle
2) Using the rapid method with the help of quadrants
3) Using the rapid method with help of maximum and minimum projections
4. Morphological and chronological analysis of the ECG trace
5. To differentiate between the normal and pathological ECG

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 1. ECG INTERPRETATION
1.1. Determining the cardiac rhythm
◼ Normal cardiac rhythm is generated by the SAN = sinus rhythm characterized by:
◼1) Presence of normal P waves in all the leads with the following characteristic:

- (+) in most leads (mandatory in lead II, III, aVF) and (-) in aVR
- Round and symmetrical
- Duration between 0.06 and 0.10 seconds
- Amplitude between 0.10 and 0.25 mV
◼2) Presence of a normal QRS complexes after every P wave

◼3) At regular PQ intervals, duration between 0.12 and 0.21 seconds

QRS
iPQ

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 1.1. Calculating heart rate (HR)

• Respiratory sinus arrhythmia

− HR is modified based on the respiratory phase
• in inspiration: HR   iRR is shortened
• in expiration: HR   iRR este prolonged
− It is recognized on the ECG by the presence of sinus rhythm, variable RR
− role: optimizing the pulmonary gas exchange
− Frequently seen in children and adults with good cardiovascular state
(athletes, swimmers, cyclists)

inspiration expiration

iRR  iRR  iRR  iRR 

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 1.2. Calculating heart rate (HR)

1) An exact method – with the help of below mentioned formula:

60 60 1500
HR(b/min) = = =
iRR (s) iRR (mm) x 0,04 iRR (mm)

• Example:

60 60 1500 1500
HR = = = = = 79b / min
iRR (s) iRR (mm) x 0,04 iRR (mm) 19 (mm) 6
 1.2. Calculating heart rate (HR)
2) Indirect method (approximate value)
a) Reporting the number of heart beats at 5 mm intervals
− locate an R wave that overlaps on a thick line (START) and locate the
next R wave
− Thick lines succeeding the first R corresponds to the HR: 300, 150, 100,
75, 60, 50 b/min, etc, obtained with the formula HR = 1500 iRR(mm)
− If the 2nd R wave overlaps a thick line, HR is the one corresponding to
that thick line
− If the 2nd R wave does not fall on a thick line, then the HR is
approximated 1500/5 1500/10 1500/15 1500/20 1500/25 1500/30

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• Example: HR = 75-100 b/min, closer to 75 b/min  FC ≈ 80 b/min 7
 1.2. Calculating heart rate (HR)
2) Indirect method (approximate value)
a) Counting R waves over a period of 3 seconds (15 large squares)
− For short ECG tracing: HR can be obtained by multiplying the number
of R waves found over a period of 3 seconds (15 large squares) by 20
− For long ECG tracing: HR is obtained by multiplying the number of R
waves found over a period of 6 seconds (30 large squares) by 10
− This method is useful for calculating average HR in case of irregular
heart rhythm (e.g. calculation of ventricular rate – VR in atrial
fibrillation; ventricular rate = ventricular frequency)
D II

15 pătrate mari
V1

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• Example: AV = 5 x 20 = 100 b/min
 1.2. Calculating heart rate (HR)

• Normal values: HR
75
= 60 - 100 b/min
R
100 1500 1500
150 Exemple : FC = = = 93b/min
iRR (mm) 16 (mm)
300
iRR=16 mm

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• Example: HR=75-100 b/min, closer to 100 b/min HR≈90-95 b/min
 1.2. Calculating heart rate (HR)

• HR variations if it is sinus rhythm:

- HR > 100 b/min  Sinus tachycardia (↑SNS)
1500 1500
150
HR = = = 150b/min
R 300 iRR (mm) 10 (mm)

iRR=10 mm

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• Example: FC≈ 150 b/min
 1.2. Calculating heart rate (HR)
• HR variations if it is sinus rhythm:
- HR < 60 b/min  Sinus bradycardia (↑PSNS)
1500 1500
HR = = = 50b/min
iRR (mm) 30 (mm)

iRR=30 mm

75 60 50
100
R 150

300

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• Example: FC = 50-60 b/min, closer to 50 b/min  HR≈50-55b/min
 1.3. Determining the electrical axis of the heart

• In frontal plane, the electrical orientation of the heart:

− varies around the antero-posterior axis, from horizontal to vertical
− can be assessed by analyzing the morphology of the QRS complex in the
limb leads
• In horizontal plane, the electrical orientation of the heart:
− Varies around the longitudinal axis, from one clockwise rotation to one
anti-clockwise direction
− Can be appreciated by analyzing the morphology of the QRS complex in
the precordial leads
• The most important cardiac vector is the vector/electric axis of the QRS
complex, because it represents the vector of the largest myocardial mass
• Generally, the electrical axis of the heart overlaps in the frontal plane with
the anatomical axis of the heart
• The electrical axis of the heart is determined by the classic method and the
fast or the rapid method
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 1.3. Determination of the electrical axis of the heart
1) Classical method – Einthoven’s triangle method
• two bipolar limb leads are chosen (I and II, or I and III, or II and III)
• the amplitude of the QRS complex is measured as an algebraic sum of the
amplitudes of the component waves  the obtained value is a vector that
represents the projection of the heart axis on that lead
• the two vectors that are obtained are noted on the corresponding sides of
the triangle, taking into account the sign and starting the inscription in the
middle of the lead (0), which is considered the origin of the vector
• for each vector a perpendicular line is drawn from its origin to its vertex
• the perpendiculars from the origins of the two vectors intersect at point O
 the origin of the electrical axis of the heart
• the perpendiculars through the vertices of the two vectors intersect at
point A  the vertex of the electrical axis of the heart
• the points O and A are joined  vector OA = electrical axis of the heart
• extend the vector OA until it intersects the circle and express in degrees the
angle of the horizontal line passing through the point O:
− values (+), if inscribed in the lower half of the circle (0→ +180) 13
− values (-), if inscribed in the upper half of the circle (0 → -180)
 1.3. Determining the electrical axis of the heart

I Q=0 II Q = -1
R = +5 R = +15
S = -3 S=0
14
+2 +14
 1.3. Determining the electrical axis of the heart

-90°
I = +2
II = +14

R - DI 2 + L
- -

O
180° 0°
DIII
DII

14

+ F + 80° → electrical axis verticalised

+90° 15
 1.3. Determining the electrical axis of the heart
2) Fast method for finding the electrical axis of the heart – Quadrant method
• Is based on the appreciation of the electrical axis according to the sign of
the QRS complex (it is determined as the algebraic sum of the wave
components) in leads I and aVF:
a) QRS positive in lead I and aVF  electrical axis is between 00 and + 900

- 900
+

DI
1800 00
+

aVF

+ 900
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 1.3. Determining the electrical axis of the heart
2) Fast method for finding the electrical axis of the heart – Quadrant method
• Is based on the appreciation of the electrical axis according to the sign of
the QRS complex (it is determined as the algebraic sum of the wave
components) in leads I and aVF:
b) QRS negative in lead I and positive in aVF  electrical axis between + 900 and
1800
- 900

_
DI
1800 00
+

aVF
+ 900

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 1.3. Determining the electrical axis of the heart
2) Fast method for finding the electrical axis of the heart – Quadrant method
• Is based on the appreciation of the electrical axis according to the sign of
the QRS complex (it is determined as the algebraic sum of the wave
components) in leads I and aVF:
c) QRS negative in lead I and aVF  electrical axis between - 900 şi 1800

- 900

_
DI
1800 00

aVF
+ 900

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 1.3. Determining the electrical axis of the heart
2) Fast method for finding the electrical axis of the heart – Quadrant method
• Is based on the appreciation of the electrical axis according to the sign of
the QRS complex (it is determined as the algebraic sum of the wave
components) in leads I and aVF:
d) QRS positive in lead I and negative in aVF  electrical axis is between 00 and –
900
• Aspect of the QRS complex must be analyzed in leads II:
‒ If it is positive, then the axis is horizontal (between 0 and -30)
‒ If it is negative, then the axis is deviated towards the left (between -30
and -90)- 900
+

DI
1800 00

_
aVF
19
19
+ 900
 1.3. Determining the electrical axis of the heart
2) Fast method for finding the electrical axis of the heart – Quadrant method

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 1.3. Determining the electrical axis of the heart

• Example:
• QRS (+) in DI
 Electrical axis between 00 and + 900
• QRS (+) in aVF 
Electrical axis
• QRS (DI) << QRS (aVF)  electrical axis is closer to aVF is
vertical 21
 1.3. Determining the electrical axis of the heart

3) Fast method to determine the electrical axis of the heart based on

maximum and minimum projections
- The lead in which the complexes of maximum amplitude are registered →
the axis is parallel to this lead
- The lead in which the complex is registered to have minimum amplitude →
the axis is perpendicular to this lead
- Observation: the registration of a complex of increased amplitude in a
certain lead is considered to be a real maximum only if a complex of a
minimum amplitude is noted in the opposite lead

ELECTRICAL AXIS MAXIMUM MINIMUM

PROJECTION PROJECTION (NULL)
00 DI AVF
+ 300 AVR DIII
+ 600 DII AVL
+ 900 aVF DI 22
 1.3. Determining the electrical axis of the heart

• Example:
• Maximum projection in aVF  electrical axis // with aVF 
ax electric
• Minimum projection in lead I  electrical axis ⊥ to DI verticalizat23
 1.3. Determining the electrical axis of the heart

Normal values: - 30° → +110°

• Horizontal axis: - 30° → +30°
• Intermediate axis: + 30° → +60°
• Vertical axis: + 60° → +110°

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 1.3. Determining the electrical axis of the heart

Physiological variations of the electrical axis

• Depending on the body stature
− The electrical axis is vertical in tall people
− The electrical axis is horizontal in short stature

• Depending on the age

− The electrical axis is deviated towards right side in children and
adolescents
− The electrical axis is deviated towards the left side in elderly

• Depending on the physiological state

− The electrical axis is horizontal or deviated towards the left in pregnant
females

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 1.3. Determining the electrical axis of the heart

Pathological variations:
• Left axis deviation: -30° → -90°
− In left ventricular hypertrophy, left bundle branch block
• Right axis deviation: +110° → 180°
− In pulmonary hypertension, in some right bundle branch block cases
• Extreme right axis deviation: -90° → 180°
− Incorrect placement of electrodes, dextrocardia

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 1.4. Morphological and chronological analysis of the ECG
ECG Components Normal characteristics
P wave - Aspect rounded and symmetric
Direction (+) in majority of the leads, has to be (-) in aVR and sometimes biphasic
in V1
Duration 0.06 – 0.10 s
Amplitude 0.10 – 0.25 mV (maximal in lead II)
QRS complex
Aspect Monophasic, biphasic or triphasic
Durată 0.08 – 0.10 s
Amplitude 1 – 1.5 mV; minimum 0.5 mV in leads I, II, III; minim 1 mV in precordials
Sokolov-Lyon Index SV2 + RV5< 35 mm or RV1 + SV6 < 10.5 mm
T wave Rounded, asymmetric, with the ascending slope more gradual,
Aspect compared to the descending slope which is more abrupt
Direction Concordant with QRS complex, (+) in majority of the leads, (-) in aVR
Duration 0.13 – 0.30 s
Amplitude less than 1/3rd of the QRS complex amplitude
PQ segment Isoelectric line, duration 0.06 – 0.12 s
ST segment Isoelectric line (+/- 1 mm), duration 0.05-0.15 s
PQ interval Duration 0.12 – 0.21 s
ST interval Duration is not measured
QTc interval Duration 0.35 – 0.45 s 27
 2. PRACTICAL EXCERSISES

Record and interpret the ECG completing the below mentioned details:

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2. PRACTICAL EXCERSISES

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 3. CLINICAL APPLICATION

1. A 55 year old male patient presents to the family doctor with complaint of
getting fatique while performing daily routine houshold activities. The
below given ECG was recorded

Which is the electrical axis?

A. -170°
B. -20°
C. 0°
D. +60°
E. +170°

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 3. CLINICAL APPLICATION

I Q=0 II Q=0
R = +3 R = +2
S = -25 S = -12
-22 -10 31
 3. CLINICAL APPLICATION
-90°

I = -22
II = -10
R - DI + L
- -

O
180° A 0°
DIII
DII
+170°

+ F +
+90°

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Electrical axis is at +170°  right axis deviation  correct answer E
 3. CLINICAL APPLICATION

2. Electrocardiogram of a 60 year old male shows R-R interval of 0.55 s. Which

of the following statements can best explain his state?
A. He is having tachycardia
B. He has normal HR
C. He is suffering from parasympathetic hyperstimulation at the the level of
AV node
D. Is a trained athelete in resting state
E. He is having bradycardia

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 3. CLINICAL APPLICATION

• Heart rate is determined by the formula:

60 60
HR = = = 109b/min
iRR(sec) 0,55(s)

• HR100 b/min  tahycardia  correct answer is A

• B (normal heart rate) and E (bradycardia) are incorrect
• Answer C is incorrect, as parasympathetic hyper stimulation at the level of
AV node prolongs the atrio-ventricular conduction and hence decreases the
heart rate (bradycardia)
• Option D is incorrect, as in trained atheletes the HR is decreased in resting
state

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 3. CLINICAL APPLICATION

3. A 62 year old male, 114 kg body weight, with a 30 year history of smoking,
performs an ECG evaluation in the hospital. The findings are shown below

Which is the electrical axis?

A. –110°
B. –20°
C. +90°
D. +105°
E. +180°

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3. CLINICAL APPLICATION

I Q = -10 II Q = -3
R=0 R = +21
S=0 S=0
-10 +18

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 3. CLINICAL APPLICATION
-90°

I = -10
II = +18
R - DI + L
- -

O
180° 0°
DIII
DII

A + F +
+90°
+105°
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Electrical axis is at +105° (normal)  correct answer is D
 3. CLINICAL APPLICATION

4. An ECG recording performed at the family doctors cabinet of a 30 year old

male, was lost. The doctor remembers that the patient had large positive
QRS complex in aVF and 0 in lead I. Which is the electrical axis of the heart
in the frontal plane of this person?
A. +90°
B. +60°
C. 0°
D. -60°
E. -90°

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 3. CLINICAL APPLICATION
-90°

I=0
aVF = +
R - DI + L
- -

O
180° 0°
DIII
DII

+ F +
+90°

Electrical axis is at +90° (noraml vertical electrical axis)  correct answer A 39

 3. CLINICAL APPLICATION

5. ECG is recorded of a 55 year old male. Net deflection (R wave – Q wave or

S) in lead I is -1.2 mV, while in lead II it is +1.2 mV. Which is the cardiac
electrical axis of this patient?
A. –30°
B. +30°
C. +60°
D. +120°
E. –120°

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 3. CLINICAL APPLICATION
-90°

I = -1.2
II = +1.2
R - DI + L
- -

O
180° 0°
DIII
DII

+120° + F +
+90°

Electrical axis is at +120° (normal vertical electrical axis)  correct answer D41
 4. MCQ’s
Note: questions marked with * have only one correct answer, the others have
2 or 3 correct answers.

1. Which of the following statements are criteria for recognizing sinus rhythm:
A. Presence of the QRS complex followed by the T wave
B. Presence of positive P wave in most leads and negative P wave in aVR
C. Regular PQ intervals, lasting between 0,12 - 0,21 s
D. Presence of P wave followed by the QRS complex
E. Absence of the P wave

2. Which of the following statements about heart rate are correct:

A. The normal heart rate is between 40 and 60 beats/min
B. Quick methods allow an accurate calculation of heart rate
C. Heart rate above 100 beats/min is called tachycardia
D. The direct method estimates the value of the heart rate
E. The normal heart rate is between 60 and 100 beats/min

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 4. MCQ’s

3. Which of the following statements are false:

A. The normal axis of the heart is between -30° and +110°
B. The left axis deviation is present when the axis is between 0° and -30°
C. The intermediate electrical axis is between +30° and +60°
D. The normal horizontal electrical axis is between 60° and +110
E. The right axis deviation is present when the axis is between +110° and
+180°

4. *Respiratory sinus arrhythmia is characterized by:

A. It occurs most frequently in the elderly
B. Heart rate increases during expiration
C. heart rate decreases during inspiration
D. Heart rate increases during inspiration and decreases during expiration
E. On the ECG it is highlighted by a constant RR interval
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 4. MCQ’s

5. Physiological variations of the electrical axis can be found:

A. In the left bundle branch block
B. In left ventricular hypertrophy
C. In pregnant females
D. In tall individuals
E. In pulmonary hypertension

6. The following statements about the P wave are true:

A. It is rounded and symmetrical
B. It is rounded and asymmetrical, with a gradually ascending slope and an
abruptly descending slope
C. It is positive in all 12 leads
D. It has a normal duration between 0,06 and 0,10 s
E. Normally, it has an amplitude less than 1/3 of the QRS complex
amplitude
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 4. MCQ’s

7. *If the ventricular depolarization wave has the electric axis displaced in the
frontal plane at +150°, in which lead does a negative wave with maximum
amplitude will appear?
A. aVR
B. II
C. aVL
D. III
E. aVF

8. *Taking into consideration the rapid method for determining the electrical
axis of the heart, the following statements are correct except
A. QRS (+) in DI and aVF corresponds to electrical axis between 0 & -90
B. QRS (+) in DI and aVF corresponds to electrical axis between 0 & +90
C. QRS (+) in DI & (-) in aVF corresponds to electrical axis between 0 &-90
D. QRS (+) in aVF & (-) in DI corresponds to electrical axis between+90& +180
E. QRS (-) in DI & aVF corresponds to electrical axis between -90 & -180
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 4. MCQ’s

9. Which of the statements is false:

A. In atrial fibrillation P waves are replaced by small and irregular QRS
complexes
B. In atrial fibrillation RR interval is irregular
C. Normal P waves are present in atrial fibrillation
D. "F“ waves are present in the atrial flutter
E. "f“ waves are present in atrial fibrillation

10. Choose the correct answer:

A. The left axis deviation may be present in the LBBB
B. Right axis deviation is not present in pulmonary hypertension
C. In obese people we usually encounter a right axis deviation
D. If the QRS is (+) in DI and aVF, the heart’s electrical axis is deviated to the
left
E. The left axis deviation is present in left ventricular hypertrophy (LVH)
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 Take home messages!
• ECG analysis provides important information about the electrical activity of
the heart, being one of the most used investigations in the clinic, but it has
some limitations:
− for the diagnosis of AMI, the ECG sensitivity is only 30%
− for rhythm disorders, the ECG sensitivity is over 90%
• Given the limitations of the data provided by the simple 12-lead ECG,
further investigations (mentioned below) are needed:
− 24-hour ECG recording (Holter monitoring)
− ECG recording several leads
− Imaging investigations: echocardiography, coronary angiography, angio-
MRI and coronary angio-CT
− Exercise ECG
− Laboratory investigations

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