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10 Steps to Learn ECG Interpretation
Learning the art of ECG interpretation requires intellect, commitment, e ort and — perhaps most
importantly — an organized approach. I personally have spent thousands of hours (yes, thousands)
looking at 12-lead ECG tracings, studying ECGs for the cardiology boards, interpreting ECGs for direct
patient care and developing ECG tutorials and quizzes for LearntheHeart.com.
Assuming that most of you reading this blog do not have that much time, please allow me to share
what I have discovered in my years teaching ECGs to make the process more simple — and maybe
even enjoyable.

ECGs Made Easy?

I imagine it is understood that learning all of ECG interpretation is going to take more than 10
minutes of your time and that it is not quite so easy. To be proficient, it will take a bit of e ort. Some
memorization and pattern recognition will be required. The more you see, the more you will
remember. Having a pair of calipers is helpful. But when using LearntheHeart.com to learn ECGs,
don’t scratch your computer monitor please. Now that this is understood, let’s get down to it.

Step 1. Learn the Basics of a 12-lead ECG Tracing

First things first. Knowing the basic parts of an ECG tracing will lay a good foundation for everything
else that is to come. The di erent waves, complexes and intervals need to be ingrained in your brain.
How many seconds is a full ECG tracing? How much time does each big box and each little box
represent?
This is not the time to learn the crazy things such as the di erent P-wave morphologies that occur
with atrial enlargements and ectopic atrial rhythms — but rather, just to know what the normal P
wave looks like and what it represents. It’s a similar concept for the other parts of the ECG.

Read ECG Basics.

Step 2. Determine Heart Rate on the ECG

To determine whether bradycardia, a normal heart rate or tachycardia is present requires the
knowledge to calculate the heart rate on the ECG. Remember to apply these techniques to both the
atrial rate, measured by the rate of the P wave, and the ventricular rate, measured by the rate of the
QRS complex.

Read Determining Rate.

Step 3. Determine Axis on the ECG

The axis on the ECG can give a clue to many di erent pathologic states. Unless you are going into
electrophysiology as a career, the only axis that you need to measure is that of the QRS complex.

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Be sure to know the causes of le axis deviation, right axis deviation and when the axis is
indeterminate (northwestern). Also, know the quick shortcuts to determine the axis.

Read Determining Axis.

Step 4. Learn Abnormal Heart Rhythms

Learning a normal sinus rhythm was taken care of in Step 1. Now, learn the below rhythms like the
back of your hand. Be sure to review multiple examples of each in the individual ECG Reviews and
Criteria sections below.

Atrial Fibrillation ECG Review

Atrial Flutter ECG Review

Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review

Atrioventricular Reentrant Tachycardia (AVRT) ECG Review

Ectopic Atrial Rhythms ECG Review

First-Degree Atrioventricular (AV) Block ECG Review

Idioventricular Rhythms ECG Review

Junctional Rhythms ECG Review

Multifocal Atrial Tachycardia (MAT) ECG Review

Second-Degree Atrioventricular (AV) Block Type I (Wenkebach) ECG Review

Second-Degree Atrioventricular (AV) Block Type II ECG Review

Sinus Arrhythmia ECG Review

Sinus Bradycardia ECG Review

Sinus Tachycardia ECG Review

Third-Degree Atrioventricular (AV) Block ECG Review

Ventricular Tachycardia (VT) ECG Review

Wandering Atrial Pacemaker (WAP) ECG Review

Step 5. Learn Chamber Hypertrophies and Bundle Blocks

Sometimes this can be the most di icult part. Atrial enlargements are not too bad, but the criteria
for le ventricular hypertrophy can drive you crazy. No need to memorize then all, just the main two
or three.

Le and right bundle branch are not too bad, either. The “bunny ears” are easy to spot in right
bundle branch blocks — though not always present. Don’t forget to learn what a non-specific
interventricular conduction delay looks like, as well.
Bifascicular Block ECG Review

Le Anterior Fascicular Block (LAFB) ECG Review

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Le Atrial Enlargement (LAE) ECG Review

Le Bundle Branch Block (LBBB) ECG Review

Le Posterior Fascicular Block (LPFB) ECG Review

Le Ventricular Hypertrophy (LVH) ECG Review

Poor R Wave Progression ECG Review

Right Atrial Enlargement (RAE) ECG Review

Right Bundle Branch Block (RBBB) ECG Review

Right Ventricular Hypertrophy (RVH) ECG Review

Trifascicular Block ECG Review

Step 6. Learn Acute MI and Ischemic ECG Findings

This is the fun part of ECG interpretation. Some of the acute MI ECG findings, such as anterior ST
segment elevations and inferior ST segment elevation MIs, are obvious. The tough part is identifying
the more subtle ECG changes.

Know when ST segment elevation is due to ischemia and when it is due to other causes including le
ventricular aneurysm or le ventricular hypertrophy. Likewise, know when ST segment depression
is due to digoxin ECG changes.

Anterior Wall ST Segment Elevation Myocardial Infarction (MI) ECG Review

Inferior Wall ST Segment Elevation Myocardial Infarction (MI) ECG Review

Posterior Wall Myocardial Infarction (MI) ECG Review

Step 7. Learn the Everything Else Including Atypical ECG

Findings
Again, some repetition and memorization is required. The list of things that go into this category is
long — so let’s get going.

Arrhythmogenic Right Ventricular Dysplasia (ARVD) ECG Review

Atrial Septal Defect (ASD) ECG Review

Brugada Syndrome ECG Review

Dextrocardia ECG Review

Digoxin E ect ECG Review

Early Repolarization ECG Review

Hypercalcemia ECG Review

Hyperkalemia ECG Review

Hypertrophic Obstructive Cardiomyopathy (HOCM) ECG Review

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Hypocalcemia ECG Review

Hypokalemia ECG Review

Hypothermia ECG Review

Le Ventricular (LV) Aneurysm ECG Review

Limb Lead Reversal ECG Review

Lown-Ganong-Levine Syndrome ECG Review

Low Voltage ECG Review

Neurologic Insult ECG Review

Pericarditis ECG Review

Prolonged QT Interval ECG Review

Pulmonary Embolism ECG Review

Wellens’ Syndrome ECG Review

Wol -Parkinson-White (WPW) ECG Review

Step 8. Quiz, Quiz, Quiz and Review, Review, Review

Taking ECG quizzes, then reviewing once again when you identify a gap in your knowledge, is key.
You can never look at too many 12-lead ECG tracings. In my opinion, you should not take a quiz that
only shows a snippet of an ECG, a QRS complex or just a rhythms strip. In real life, you see full 12-
lead ECG tracings — so that is how you need to test yourself.

Step 9. Review ECGs in Real Patient Case Scenarios

Whether you are a medical student in clinical rotations, an EMT or an internist in practice, looking at
the ECGs that you encounter in practice is important. See how the ECG fits the clinical scenario.
Sometimes the best way to remember an ECG findings is to associate it with an interesting case that
you experienced personally.

Alternatively, you can practice some ECG cases — online or in a textbook — in which a patient
scenario is presented to you, then the ECG that goes along with it is revealed.

Step 10. Teach Others How to Read an ECG

There is no question whatsoever in my mind that I personally have learned the most about ECG
interpretation by developing content for LearntheHeart.com and teaching ECG courses in person. If
you can put yourself in a position to teach students or your colleagues about ECGs, you will solidify
your skills tremendously. Teach your spouse or your dog. Whatever works for you.

The Practice of Medicine – Never Stop Learning

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Just keep on reviewing. One day, you will stop and think “Wow, I think I get it.” Sure, you can
memorize every criteria and detail about the various ECG findings. But with the availability of
internet access in the hospital and on your smartphone, why not just bookmark a nice reference
page? Eventually, if you look things up enough times, you will commit them to memory.

Follow an ECG blog, and read the articles regularly. This will keep things fresh in your mind and
introduce you to crazy and/or rare ECG tracings.

– by Steven Lome, DO, RVT

RELATED CONTENT: Atrial Arrhythmias ECG Quiz | Beginner ECG Quiz | Chamber
Enlargements and Axis ECG Quiz | Comprehensive ECG Quiz | Expert ECG Quiz | Heart Blocks
ECG Quiz | Infarcts and Ischemia ECG Quiz | Miscellaneous ECG Quiz | Ventricular Arrhythmias
ECG Quiz | ECG Cases

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