The ECG in healthy

people

The normal cardiac rhythm

The heart rate

Extrasystoles

The P wave

The PR interval

11

The QRS complex

13

The ST segment

29

The T wave

33

The QT interval

42

The ECG in athletes

43

The ECG in pregnancy

47

The ECG in children

47

Frequency of ECG abnormalities in healthy

people

49

What to do

49

For the purposes of this chapter, we shall assume

that the subject from whom the ECG was recorded
is asymptomatic, and that physical examination has
revealed no abnormalities. We need to consider the
range of normality of the ECG, but of course we
cannot escape from the fact that not all disease
causes symptoms or abnormal signs, and a subject
who appears healthy may not be so and may
therefore have an abnormal ECG. In particular,
individuals who present for screening may well
have symptoms about which they have not consulted
a doctor, so it cannot be assumed that an ECG
obtained through a screening programme has come
from a healthy subject.
The range of normality in the ECG is therefore
debatable. We first have to consider the variations in
the ECG that we can expect to find in completely
healthy people, and then we can think about the
significance of ECGs that are undoubtedly
abnormal.

The ECG in healthy people

THE NORMAL CARDIAC RHYTHM
Sinus rhythm is the only normal sustained rhythm.
In young people the RR interval is reduced (that is,
the heart rate is increased) during inspiration, and
this is called sinus arrhythmia (Fig. 1.1). When sinus
arrhythmia is marked, it may mimic an atrial
arrhythmia. However, in sinus arrhythmia each
PQRST complex is normal, and it is only the
interval between them that changes.

Fig. 1.1

THE HEART RATE

There is no such thing as a normal heart, and the
terms tachycardia and bradycardia should be used
with care. There is no point at which a high heart

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

II

Sinus arrhythmia becomes less marked with

increasing age of the subject, and is lost in
conditions such as diabetic autonomic neuropathy
due to impairment of the vagus nerve function.

The normal cardiac rhythm / The heart rate

rate in sinus rhythm has to be called sinus
tachycardia and there is no upper limit for sinus
bradycardia. Nevertheless, unexpectedly fast or
slow rates do need an explanation.

other abnormalities on examination, and her blood

count and thyroid function tests were normal.
Box 1.1 shows possible causes of sinus rhythm
with a fast heart rate.

SINUS TACHYCARDIA
The ECG in Figure 1.2 was recorded from a young
woman who complained of a fast heart rate. She had
no other symptoms but was anxious. There were no

Box 1.1 Possible causes of sinus rhythm with a fast

heart rate

Sinus arrhythmia
Note

Marked variation in RR interval

Constant PR interval
Constant shape of P wave and QRS complex

Pain, fright, exercise

Hypovolaemia
Myocardial infarction
Heart failure
Pulmonary embolism
Obesity
Lack of physical fitness
Pregnancy
Thyrotoxicosis
Anaemia
Beri-beri
CO2 retention
Autonomic neuropathy
Drugs:
sympathomimetics
salbutamol (including by inhalation)
caffeine
atropine

The ECG in healthy people

Fig. 1.2

Fig. 1.3

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

II

The heart rate

SINUS BRADYCARDIA
Sinus tachycardia
Note

Normal PQRST waves

RR interval 500 ms
Heart rate 120/min

The ECG in Figure 1.3 was recorded from a young

professional footballer. His heart rate was 44/min,
and at one point the sinus rate became so slow that
a junctional escape beat appeared.
The possible causes of sinus rhythm with a slow
heart rate are summarized in Box 1.2.

Box 1.2 Possible causes of sinus rhythm with a slow

heart rate

Sinus bradycardia
Note

Sinus rhythm
Rate 44/min
One junctional escape beat

Physical fitness
Vasovagal attacks
Sick sinus syndrome
Acute myocardial infarction, especially inferior
Hypothyroidism
Hypothermia
Obstructive jaundice
Raised intracranial pressure
Drugs:
beta-blockers (including eye drops for glaucoma)
verapamil
digoxin

Junctional escape beat

The ECG in healthy people

Fig. 1.4

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

II

Fig. 1.5

II

Extrasystoles / The P wave

Supraventricular extrasystole
Note

In supraventricular extrasystoles the QRS complex and

the T wave are the same as in the sinus beat
The fourth beat has an abnormal P wave and therefore
an atrial origin

EXTRASYSTOLES
Supraventricular extrasystoles, either atrial or
junctional (AV nodal), occur commonly in normal
people and are of no significance (Fig. 1.4). Atrial
extrasystoles have an abnormal P wave; in junctional
extrasystoles, either there is no P wave or the P wave
may follow the QRS complex.
Ventricular extrasystoles are also commonly seen
in normal ECGs (Fig. 1.5).

THE P WAVE
Early abnormal P wave

Ventricular extrasystole
Note

Sinus rhythm, with one ventricular extrasystole

Extrasystole has a wide and abnormal QRS complex
and an abnormal T wave

In sinus rhythm, the P wave is normally upright in

all leads except VR. When the QRS complex is
predominantly downward in lead VL, the P wave
may also be inverted (Fig. 1.6).
A notched or bifid P wave is the hallmark of left
atrial hypertrophy, and peaked P waves indicate
right atrial hypertrophy but bifid or peaked P
waves can also be seen with normal hearts.
In patients with dextrocardia the P wave is
inverted in lead I (Fig. 1.7). In practice this is more
often seen if the limb leads have been wrongly
attached, but dextrocardia can be recognized if leads
V5 and V6, which normally look at the left
ventricle, show a predominantly downward QRS
complex.
If the ECG of a patient with dextrocardia is
repeated with the limb leads reversed, and the chest
leads are placed on the right side of the chest instead
of the left, in corresponding positions, the ECG
becomes like that of a normal patient (Fig. 1.8).

Ventricular extrasystole

The ECG in healthy people

Fig. 1.6

Fig. 1.7

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

The P wave

Normal ECG
Note

In both leads VR and VL the P wave is

inverted, and the QRS complex is
predominantly downward

Inverted P wave in lead VL

Dextrocardia
Note

Inverted P wave in lead I

No left ventricular complexes
seen in leads V5V6

Inverted P wave and

dominant S wave in
lead I

Persistent S wave in
lead V6

The ECG in healthy people

Fig. 1.8

Fig. 1.9

10

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

The P wave / The PR interval

Dextrocardia, leads reversed

Note

P wave in lead I upright

QRS complex upright in lead I
Typical left ventricular complex in lead V6

Upright P wave and

QRS complex in lead I

Normal ECG
Note

PR interval 170 ms
PR interval constant in all leads
Notched P wave in lead V5 is often normal

Normal QRS
complex in lead V6

THE PR INTERVAL
In sinus rhythm, the PR interval is constant and the
normal range is 120200 ms (35 small squares of
ECG paper) (Fig. 1.9).
A PR interval of less than 120 ms suggests preexcitation, and a PR interval of longer than 200 ms
is due to first degree block. Both of these
abnormalities are seen in normal people, and will
be discussed further in Chapter 2.

PR interval 170 ms

11

The ECG in healthy people

Fig. 1.10

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

Fig. 1.11

12

VR

V1

V4

II

VL

V2

V5

III

VF

V3

V6

The QRS complex

Normal ECG
Note

QRS complex upright in leads IIII

R wave tallest in lead II

Normal ECG
Note

This record shows the rightward limit of normality of

the cardiac axis
R and S waves equal in lead I

THE QRS COMPLEX

THE CARDIAC AXIS
There is a fairly wide range of normality in the
direction of the cardiac axis. In most people the
QRS complex is tallest in lead II, but in leads I and
III the QRS complex is also predominantly upright
(i.e. the R wave is greater than the S wave)
(Fig. 1.10).
The cardiac axis is still perfectly normal when the
R wave and S wave are equal in lead I: this is
common in tall people (Fig. 1.11).
When the S wave is greater than the R wave in
lead I, right axis deviation is present. However, this
is very common in perfectly normal people. The
ECG in Figure 1.12 is from a professional footballer.
It is common for the S wave to be greater than
the R wave in lead III, and the cardiac axis can still
be considered normal when the S wave equals the R
wave in lead II. These patterns are common in fat
people and during pregnancy (Fig. 1.13).
When the depth of the S wave exceeds the height
of the R wave in lead II, left axis deviation is present
(see Fig 2.26).

13