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Normally, voltage standardization is 1.0 mV per 10 mm, and paper speed is 25 mm/s (each horizontal small box = 0.04 s).

Heart Rate

Beats/min = 300 divided by the number of large boxes (each 5 mm apart) between consecutive QRS complexes. For faster heart rates, divide 1500 by number of small boxes (1 mm apart) between each QRS.


Sinus rhythm is present if every P wave is followed by a QRS, PR interval ≥0.12 s, every QRS is preceded by a P wave, and the P wave is upright in leads I, II, and III. Arrhythmias are discussed in Chaps. 122 and 123.

Mean Axis

If QRS is primarily positive in limb leads I and II, then axis is normal. Otherwise, find limb lead in which QRS is most isoelectric (R = S). The mean axis is perpendicular to that lead (Fig. 111-1). If the QRS complex is positive in that perpendicular lead, then mean axis is in the direction of that lead; if negative, then mean axis points directly away from that lead.

FIGURE 111-1

Electrocardiographic lead systems: The hexaxial frontal plane reference system to estimate electrical axis. Determine leads in which QRS deflections are maximum and minimum. For example, a maximum positive QRS in I which is isoelectric in aVF is oriented to 0°. Normal axis ranges from −30° to +90°. An axis > +90° is right-axis deviation and <30° is left-axis deviation.

Left-axis deviation (more negative than –30°) occurs in diffuse left ventricular disease, inferior MI, and in left anterior hemiblock (small R, deep S in leads II, III, and aVF).

Right-axis deviation (>90°) occurs in right ventricular hypertrophy (R > S in V1) and left posterior hemiblock (small Q and tall R in leads II, III, and aVF). Mild right-axis deviation is common in thin, healthy individuals (up to 110°).


PR (0.12–0.20 s)

  • Short: (1) preexcitation syndrome (look for slurred QRS upstroke due to “delta” wave), (2) nodal rhythm (inverted P in aVF).

  • Long: first-degree atrioventricular (AV) block (Chap. 122).

QRS (0.06–0.10 s)

Widened: (1) ventricular premature beats, (2) bundle branch blocks: right (RsR′ in V1, deep S in V6) and left (RR′ in V6 [Fig. 111-2]), (3) toxic levels of certain drugs (e.g., flecainide, propafenone, quinidine), (4) severe hypokalemia.

FIGURE 111-2

Intraventricular conduction abnormalities. Illustrated are right bundle branch block (RBBB); left bundle branch block (LBBB); left anterior hemiblock (LAH); right bundle branch block with left anterior hemiblock (RBBB + ...

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