Interpret the ECG

 

To correctly interpret the ECG must carefully consider:

 

1. Rhythm and frequency

2. Intervals

3. segment ST

4. P, T Waves

5. Q Waves

6. QRS complexes

7. Axis

 

1. The rhythm is "sinus" when the following conditions occurs:

Presence of positive P wave in leads I and aVF.

Each P wave is followed by a QRS complex and each QRS preceded by a P wave

PR interval between 0.12 and 0.2 sec. (3-5 small squares) and constant from beat to beat

Heart rate of 60-100 bpm.

Calculate the heart rate.

Method 1:

To find the heart rate you can divide the number 300 by the number of squares between two QRS complexes.

For example: 300/4=75 bpm

2 squares between RR = 150 bpm

3 squares between RR = 100 bpm

4 squares between RR = 75 bpm

5 squares between RR = 60 bpm

Method 2:

Count the number of QRS complexes in 6 seconds of ECG recording and multiply it by 10

Method 3:

Divide 1500 by the number of small squares between two QRS complexes

Method 4:

Divide 60000 for the number of milliseconds in a RR cycle.

 

2. Knowing well the meaning of waves and intervals with their "normal" values​​, it is easy to see when we have a pathological condition because of these values ​​outside of the normal range. For example, knowing that P is the atrial contraction and QRS complex the ventricular one, if the PR interval is greater than 200 ms (1 large square on the graph paper) means that there is a pathological condition in which there is a slowdown in the transmission of electrical impulses between the atria and ventricles, so we have an AtrioVentricular block (AV block).

 

3. Segments are always on the isoelectric line. When the ST segment is above the isoelectric line (ST segment elevation) is indicative of acute myocardial infarction (subepicardial ischemia), whereas when it is below the isoelectric line (ST segment depression) is a sign of subendocardial injury.

 

4. Each P wave has its own shape, duration, and can be positive (above the isoelectric line) or negative. For example, the P wave should be positive in leads aVF and I to be able to say that rhythm is sinus, otherwise it is called "atrial rhythm." The T waves are positive (except from these  in aVR). The presence of negative T waves are a sign of the suffering of the endocardium, it could mean the onset of a myocardial infarction.

 

5. Q-wave is the first of the QRS complex. It is usually a small wave, negative and short-lived. If it is very deep (at least one third of the QRS complex) and lasts for at least 40 ms we are talking about a pathological Q wave, and is a sign of a previous myocardial infarction. The presence of pathological Q waves do not have to worry because indicates a patient with - already - coronary disease but we will pay more attention in case of suspected symptoms.

 

6. The QRS complex lasts 100 ms, approximately 2.5 small squares and represents the propagation of the electrical impulse from the atrioventricular node, bundle of His, right and left branches, Purkinje fibers. If its duration is greater than normal (100 ms) means that we have a problem in the transmission of the impulse, so a Block of  Branch (BB), which may be right or left.

 

7. Determine the axis of the QRS complexes (as well as P-waves or T) is important to diagnose various diseases. To understand the axis refer to the appropriate chapter.

 

 

Leads and Axis 

 

When you perform an ECG , you see the recording of the bipolar limb leads (I, II, III) , the amplified unipolar limb leads ( aVR aVL aVF ) and precordial leads (V1 -6), for a total of 12 leads . But what exactly are these leads ?

 

Bipolar leads :

The I measures the difference in electrical potential between the left arm and right arm . All (pathological signs) that we see on this derivation will cover the left side of the heart.

The II measure the potential difference between the foot ( either left or right) and the right arm

The III measure the potential difference between the foot ( either left or right) and the left arm

Both the III and II leads concern the lower part of the heart.

The three lines that you see in the picture above , form the Einthoven triangle.

The aVR (Amplificated Vector Right) is a lead exploring the right side of the heart.

The aVL ( Amplificated Vector Left) explores the left side of the heart while the aVF ( Amplificated Vector Foot ) the bottom / diaphragmatic part of heart .

 

If we take now the three lines (axes) of the three bipolar leads (I, II, III) and move each one toward the center so that they intersect and put them in a circle, and we also add the amplified unipolar leads, we form the hexaxial reference system of the heart.

 

I = 0 °

II = + 60 °

III = +120 °

aVR = -150 °

aVL = -30 °

aVF = +90 °

 

With this system we can determine the electrical axis of the heart of the patient and that has a great clinical importance as we shall see later. Generally the axis of the QRS complex is evaluated because of its great clinical interest, although you can find the axis of any wave of the ECG.

 

To find the axis of the QRS complex we have to observe them in all the limb leads (not the precordial leads ) . There is a system to calculate the axis with accuracy but for the sake of simplicity we will not discuss it here .

You can locate the QRS axis (or P or T ) with three empirical methods :

1 ) The axis corresponds with the R-wave (P, T) of the higher lead ( between limb leads ) .

2 ) Of all the limb leads , if there is one that is not negative nor positive, this is the transition zone between the positive and negative half of the circle. The axis will be found at 90 degrees angle to it , in the half positive part.

3) You can found the electrical axis of the heart considering the polarity of the QRS in just two leads, I and aVF :

If I (+) and aVF ( + ) = mean vector of the QRS is normal

If I ( -) , and aVF (+) = right axis deviation

If I ( +) and aVF (-) = left axis deviation

If I ( -) , and aVF (-) = extreme right axis deviation

 

The normal electrocardiogram of adult (healthy) people has the mean vector of the QRS between 0 (I) and 90 (aVF). Between 0 and -90 you have the left axis deviation , and between 90 and 180 the right axis deviation . In the area between -90 and 180 we have an extreme right axis deviation .

 

What is the clinical utility of the hexaxial reference system of the heart?

Look at the circle with axes and imagine that you have in front of you a person who is watching you . The I lead (and aVL ) is his left arm , the aVR is his right arm, while the II, III and aVF are at his feet. We said that an ST -segment elevation means acute myocardial infarction, but which part of the heart is suffering ? If the ST segment elevation is on the II or III , it means that regards the lower part of the heart, near the diaphragm, which "looks" towards the feet, while if it was on I would be the left side of the heart to suffer , and so away.

A right axis deviation could mean a right ventricular hypertrophy , a posterior fascicular block or acute pulmonary embolism , while a left axis deviation could mean left ventricular hypertrophy or an anterior fascicular block .

 

The precordial leads are also unipolar and explore the heart wall directly below: V1 V2 V3 and explore the front and going to the V6 the left side of the heart. So if we find an ST segment elevation on the V2 means that the front heart wall or the interventricular septum are suffering from an acute ischemic event , with probable involvement of the anterior descending coronary artery , while in V6 ST above means that there is a suffering of the wall left heart with probable involvement of the circumflex artery , and so forth.

 

 

 

 

 

 

 

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