So the first step in reading an ECG is to look for the

presence and correctness of the standardization.

SUT AMS MEDICAL COLLEGE, TVM Only if it is so, the rest of the ECG is read.
House Surgeon’s Manual Chapter 8
ECG READING Result of Step 1: Standardization
I looked into the ECG, I found that there is a
standardization lead.
Introduction: It was looking like a rectangle. The height was
10mm. There were no half standardization leads
Step 01. Standardization: 1mv = 10sd
ECG may be read in 12 basic steps.
The basic steps are
Step 2: Calculation of Heart rate
If the rhythm is regular, count the number of big
Step 1. Standardization divisions between two adjacent R waves. Then
Step 2. Calculation of Heart rate divide the 300 with that value to get the heart rate.
Step 3. Rhythm of the Heart
Step 4. Electrical Axis Rest of it is calculated mentally
Step 5. P wave Only this amount of accuracy in calculating the
Step 6. PR Interval heart rate is required in most instances. Otherwise
Step 7. Q Wave divide 1500 by the number of small divisions
Step 8. QRS duration
Step 9. ST segment Heart Rate in Irregular Rhythm
Step 10. T wave If there is Atrial Fibrillation, count the number of
Step 11. RVH by voltage criteria QRS complexes within 6 seconds of ECG paper .
Step 12. LVH by voltage criteria Then multiply by 10 to get heart rate in 60 seconds

Step 3. Rhythm of the Heart

Step 1. Standardization Rhythm of heart is the regularity or irregularity of
the heart action. It has to be studied using a long
It is the first lead of the electrocardiogram, the lead II or V1
standard against which other leads are to be read.
It is the square waves seen at the beginning of the Normal Sinus Rhythm
ECG tracing. Normal sinus rhythm is said to be present if the
heart rate is between 60 and 100 and every P wave
What is Standardization? is followed by a QRS complex and a T wave and
When 1 millivolt of current is given by the machine intervals normal
it produces a square wave deflection of 10 small
divisions. When ECG is recorded this amplitude is Result of Step 3: The Rhythm
applied as a standard. The rhythm appeared to be regular. The heart rate
calculated was 75 per minute. Each P was followed
What is half standardization? by a QRS and T. PR interval and QRS durations
Here even when 1 millivolt of current is applied were normal. The shape of QRS was normal
there is a deflection of only five small divisions. This Step 03 – Rhythm of heart is normal sinus rhythm
is made so, if the deflections are very tall.
Step 4. Electrical Axis
Look for standardization in every ECG It is the net or ultimate direction of conduction of the
cardiac impulse from SA node to the ventricular
apex which can be represented as a straight line
vector Step 5: P wave
The normal P wave is upward convex in shape and
Determining Axis prominently seen in leads II and V1
Axis is determined by studying leads I and III alone. So look into leads II and V1 for the details
If the net deflection is upright in these two leads,
the axis is considered as normal Normal P wave
The normal P wave is not more than 2.5 mm height
Normal Electrical Axis and not more than 2.5 mm in width
If it more than this it is abnormal

P Mitrale
In the above ECG the lead I shows an upright wave When P wave is broad and notched it indicates Left
with net positive deflection and lead III shows a net Atrial Enlargement and it is most often seen in
positive wave with upward deflection. Hence axis is patients with Rheumatic Mitral Stenosis
normal
P Pulmonale
Right Axis Deviation When P wave is tall and peaked it indicates Right
atrial enlargement
It is most often seen in Chronic Corpulmonale

Result of Step 5: P wave

I studied the P wave dimensions. It was 2 mm wide.
It was 2.5 mm high. P wave shape was normal in
lead II. P was biphasic in V1 and terminal negative
Step 05 – P wave: Normal

Step 6: PR Interval
The physiological necessity, for the AV Nodal
delay, which causes the normal PR interval is that,
the same SA Nodal impulse has to activate, both
In the above ECG the lead I shows a downward atria & ventricles
wave with net negative deflection and lead III
shows a net positive wave with +ve deflection. Normal PR Interval
Hence axis is RIGHT The Normal PR Interval is 3-5 small divisions, when
measured from the beginning of P to beginning of
Left Axis Deviation QRS
In other words it is 0.12 to 0.20 seconds

The lead I shows a positive wave with net positive Prolonged PR Interval
deflection and lead III shows a net negative wave Prolonged PR interval is said to be present if the
with negative deflection. Hence axis is LEFT PR interval is equal to or more than 0.21 sec
Result of Step 4: Electrical Axis of Heart It is seen in Acute Rheumatic Fever and I degree
I looked into leads ! And III. In lead I there was a HB
positive and negative. But positive wave was more. Short PR Interval
In lead I the net deflection was positive. In lead III PR interval is said to be short when it is less than
also the net deflection was positive 0.12 seconds in duration
Step 04 - Electrical Axis: Normal
It is seen in WPW Syndrome and Junctional
Rhythm Why is Q very important?
Presence of significant Q wave indicates the
ECG showing short PR interval diagnosis of Myocardial infarction either acute or
It is a sinus rhythm with short PR interval and old
ventricular pre-excitation syndrome possibly due to It is usually preceded by the classical chest pain
WPW
There is in addition a Delta wave Whether Acute MI or Old MI?
If it is, accompanied by other evidence of acute
Result of Step 6: PR Interval Myocardial Infarction, like ST elevation or T wave
I looked at the PR segment. I measured the PR inversion it is acute; otherwise it is old
interval. It was found to be 4 small divisions. It
meant that it is 0.16 seconds in duration. It is with in Anterior wall Infarction
the normal ranges In Anterior wall Myocardial Infarction the changes
Step 06 – PR interval: Normal of MI are seen in V2-V4
If V1 also shows changes the septum is involved
Step 7: Q Wave
Q wave is defined as the first negative deflection of Inferior wall Infarction
the QRS Complex and it is normally present only in In Inferior Wall Myocardial Infarction the changes of
a few leads viz. Lead III, II, V​5​ & V​6​ and they are MI are seen in II, III and aVF
very small If V1 also shows changes the septum is involved

There can be ‘no Q’ situation Result of Step 7: Q wave

But q waves are not always present in all the leads I looked for any q waves. Small q were present in
of all persons, unlike the other waves V5 and V6. Rest of the leads were not showing any
A small q may be present in some leads q. He q present were not wide. None of them >
0.04 second.
Significance of Q waves Step 07 – Q wave: Nil pathological
The presence of a significant Q wave is highly
suggestive of a transmural myocardial infarction QRS Duration Measurement
It also means that the coronary artery is totally QRS duration is measured from the beginning of
occluded QRS to the end of QRS
Irrespective of the type and waves in the QRS
What is an insignificant ‘Q wave’?
When the ‘q wave’ is very small in size (less than QRS Patterns
0.04mm in width) it is called an insignificant q wave QRS patterns vary from individuall to individual and
Then it is an isolated finding in one lead. from lead to lead
They don’t have much significance
In which leads small ‘q’ waves are seen?
Small or insignificant q waves are seen usually in Result of Step 8: QRS duration
leads III, II, V5 and V6, in normal persons. Rest of I looked at the QRS complexes. They were looking
the leads in a normal person does not show any normal. The duration, I measured. It was 0.10
significant q wave seconds. The pattern were numerous.
Step 08 – QRS Duration: Normal
Pathological Q wave
A ‘significant Q’ or ‘pathological Q’ is one which is Step 8: ST segment
more than 0.04mm in width. It may also be more ST segment is that portion of the base line from the
than 25% of the R wave height in the same lead S wave to the beginning of T wave, Normally, it is
iso-electric ie. at the same level as that of the ST depression in ECG is due to the presence of
baseline Ischemia to the myocardium
It occurs in Angina
ST segment elevation
ST segment elevation is the elevation of the What is myocardial Ischemia?
beginning of ST segment from the baseline, when Myocardial ischemia may result in temporary or
compared to the isoelectric line or the PR segment permanent damage to the myocardium
But usually not
What is J point?
J point is the point at which the S wave ends and Causes of ST depression
the ST segment begins Down sloping ST elevation is usually due to
It is usually seen as a definite point of turn ventricular strain associated with a relative
ischemia, whereas, horizontal ST depression is due
Significance of ST elevation to absolute ischemia
Elevation of the ST segment is considered to be
due to myocardial injury in coronary artery disease Result of Step 9: ST segment
and it is the single most important criterion of I looked at the ST segment after each QRS. They
thrombolytic therapy were flat and isoelectric. I compared them with the
P segments. They were at the same level. There
Pathophysiological Co-relation was no point elevation or depression
The degree of ST elevation in the ECG directly Step 09 – ST segment is isoelectric
correlates with the pathophysiology of CAD
Hence it the indication for thrombolysis Step 10. T wave
T wave is the upward convex wave following the
Differential diagnosis of ST elevation QRS complex and it represents ventricular
Pericarditis is characterized by the presence of ST repolarization
elevation with upward concavity, present almost in
all the leads and associated with PR segment Normal T wave
depression The normal pattern of T wave is upward and
convex in all the leads of the ECG except aVR and
Early Repolarization V​1 ​; it is inverted in these leads
It is a normal variant seen mostly in young males
characterized by J point elevation What is tall peaked T wave?
To be differentiated from Acute MI and Pericarditis T wave is said to be tall and peaked when it is very
tall and equal to or more than the preceding R
Comparison of ECG changes wave and along with an elevated ST suggestive of
ST/T Ratio in V6 of <0.25 against Pericarditis and a acute MI
less ST(equal to or less than 0.05mV) against
Acute Myocardial Infarction Significance of peaked T
Tall and peaked T waves along with ST elevation in
Whether there is ST depression? a set of ECG leads are the earliest evidence of
The ST segment is normally at the same level as acute coronary syndrome called Hyperacute
that of the iso-electric line/PR segment. When it is Myocardial Infarction
depressed by1mm from the baseline, it is called ST
depression Other important cause of tall peaked T
Peaked T, along with decreased p wave amplitude
What is ST depression due to? and widening of QRS complex suggest
hyperkalemia
It is also a potentially fatal disorder Anterior Wall MI; if lead V1 is involved it is termed
anteroseptal MI
Types of T wave inversion
In Acute MI the terminal portion of the peaked T Coronary Occlusion
wave is inverted resulting in a biphasic T wave; In Anterior wall myocardial infarction means that the
other forms of ischemia the T wave is usually left anterior descending branch of the left coronary
symmetrically inverted artery is occluded by a thrombus

ECG with T inversions

ST depression along with T wave inversions are Acute Anteroseptal MI
seen in leads II, III and aVF and the chest leads V4, ST elevation and tall peaked T waves are seen in
V5 and V6 suggesting ischemia of the inferior and the anterior precordial leads
lateral walls No q waves have appeared

Result of Step 10: T wave Antero-septal MI evolved phase

I looked at the T wave in all leads. They were Here the ST is still elevated the T wave is upright in
upright in all leads the chest leads V1 to V4
With the exception of leads aVR and V1. T shape Q waves have appeared in the same leads
was now inspected. There were no peaked or
inverted T waves. Lateral Wall Infarction
Step 10 – T wave: Normal Changes of Acute MI , when seen in the lateral
chest leads, from 1, aVL, V5 V6, it is diagnostic of
Changes occurring in Acute MI Lateral Wall Myocardial Infarction
In normal persons ECG the q wave is absent or
insignificant, ST isoelectric and T upright in all Deep Circumflex occlusion
leads It is also inferred from this, that it is the deep
There is no evidence of MI circumflex branch of the left coronary artery, is
occluded, either by a plaque or thrombus

ECG changes after Acute MI Acute Myocardial Infarction

After Acute Myocardial Infarction, q wave appears, Diffuse ST elevation with reciprocal changes
ST is elevated and the T wave is inverted in the Anterior lateral and inferior walls are involved and
leads affected there is atrial fibrillation also
The evidence of MI
Inferior Wall Infarction
Progressive changes during MI Changes of Acute Myocardial Infarction, when seen
Seen is the normal ECG followed by the in the inferior chest leads, namely II, III and aVF is
progressive changes in acute myocardial infarction diagnostic of Inferior Wall MI
Peaked T, ST elevation, loss of R and T inversion
Right coronary artery occlusion
Progressive changes after MI It is also inferred from this, that it is the right
ECG changes in the post MI period coronary artery, which supplies the inferior or
The ST elevation gets resolved, T inversion diaphragmatic surface, is occluded, either by a
gradually disappears and the Q waves if any persist plaque or thrombus

Anterior Wall MI Acute Inferior Wall MI – Early stage

Changes of Acute MI , when seen in the anterior Changes are seen in the leads II, III and aVF;
chest leads, from V1 to V4 it is diagnostic of hence it is Inferior wall MI
There is ST elevation and reciprocal changes also Depending upon ECG findings further assessment
made
Acute Inferior Wall MI in ECG
There is ST elevation, Upright and peaked waves Acute Coronary Syndrome
in II, II and aVF The algorithmic management of a patient with
It is acute Inferior wall MI Acute Coronary Syndrome is also now based on
the ECG
Antero-lateral Infarction Cardiac markers assist the diagnosis
Changes of Acute MI are seen in all the anterior
chest leads, from V1 through V6 Step 11: Right Ventricular Hyprtrophy
It is diagnostic of Antero-lateral Wall MI Normally the R wave in lead V1 is less than S wave
in the same lead. If R wave height is found to be
Left Coronary Stem Occlusion more than S wave depth in lead V1 it is the voltage
The left coronary artery, which supplies the whole criteria for RVH
of the anterior wall of heart is occluded at the stem,
involving the area supplied by both the branches Right Ventricular Hypertrophy
The height of the R wave in V1 and depth of the S
True Posterior MI wave in V1 is measured and these are compared
Changes are in the V1 lead of ECG as mirror The R wave in V1 is taller than the S wave in V1
image. These are Tall R instead of Q, ST
depression instead of ST elevation and upright T Result of Step 11: RVH by voltage criteria
instead of T inversion I looked at lead V1. Measured the height of r wave
– 4 mm. I looked at lead V1 again. Measured the
Right Ventricular Infarction depth of S wave – 16 mm. The r wave height is less
The changes of myocardial infarction are visible in than S wave depth
the right ventricular leads, V3R & V4R Step 11 – No RVH by voltage criteria
It is a right ventricular Infarction
Step 12: S in V1 + R in V6
ECG of RVMI If the depth of S wave in lead V1 + R wave height
Right sided leads shown separately on the right in V6 is more than 35mm, it satisfies the voltage
side of the panel shows ST elevation criteria for Left Ventricular Hypertrophy
The diagnosis is Inferior Wall MI + RV MI
Left ventricular hypertrophy
Transmural and subendocardial The depth of the S wave in V1 is measured and
Previously, abnormal Q waves were considered to added to the height of the R wave in V6
be markers of trans-mural MI, while The total is more than 35 mm It is LVH
sub-endocardial infarcts were thought not to
produce Q waves Result of Step 12: LVH by voltage criteria
I looked at lead V1. Measured the depth of S wave
Q waves are more important – 12 mm.. I looked at lead V6. Measured the height
Now we know that Trans-mural Infarcts may occur of R wave – 16 mm.. Added these two. The result
without presence of Q waves and subendocardial was 28 mm
infarcts may produce Q waves Step 12 – No LVH by voltage criteria

ECG in ACS Thus ECG is read simply

When a patient presents with acute onset of chest 1. Std
pain, ECG is the first line of investigation 2. Rate
3. Rhythm
4. Axis
5. P
6. PR
7. Q
8. QRS
9. ST
10. T
11. R/S in V1
12. SV1+RV6