Most coomon ecgs in clinical practice in detailed picture

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common ECG patterns clinical practice 12-lead electrocardiogram

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atrial fibrillation ECG irregular rhythm no P waves

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STEMI ST elevation myocardial infarction ECG

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left bundle branch block right bundle branch block ECG

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ventricular tachycardia ventricular fibrillation ECG arrhythmia

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sinus bradycardia tachycardia normal sinus rhythm ECG

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complete heart block first degree second degree AV block ECG

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atrial flutter ECG sawtooth pattern

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left ventricular hypertrophy ECG criteria

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Most Common ECGs in Clinical Practice — Detailed Visual Guide

1. Normal Sinus Rhythm & Sinus Rate Variants

Normal sinus rhythm: Rate 60–100 bpm, regular P waves before every QRS, PR interval 120–200 ms, narrow QRS (<120 ms), positive P in II, negative in aVR.

Key variants shown below — sinus bradycardia (<60 bpm), sinus tachycardia (>100 bpm), sinus arrhythmia, sinus block, sinus arrest:

Sinus Rhythm Variants — bradycardia, tachycardia, arrhythmia, block, arrest

Feature	Bradycardia	Normal	Tachycardia
Rate	<60 bpm	60–100 bpm	>100 bpm
P–QRS relationship	1:1, upright in II	1:1	1:1
QRS width	Narrow	Narrow	Narrow

2. Atrial Fibrillation (AF)

The most common sustained arrhythmia in clinical practice.

ECG hallmarks:

Irregularly irregular R–R intervals (no two are the same)
Absent P waves — replaced by chaotic fibrillatory (f) waves, best seen in V1 and II
Narrow QRS (unless aberrant conduction or accessory pathway)
Ventricular rate varies (controlled <100 bpm; rapid response >100 bpm)

Atrial Fibrillation — classic irregularly irregular narrow-complex tachycardia, absent P waves

AF with rapid ventricular response (~126 bpm) — fine f-waves in V1

Coarse AF (large f-waves) can mimic atrial flutter — distinguish by lack of consistent sawtooth baseline.

3. Atrial Flutter

ECG hallmarks:

Classic "sawtooth" flutter waves (F-waves), rate ~300 bpm atrial
Best seen in inferior leads (II, III, aVF) and V1
Regular or variable ventricular response — commonly 2:1 conduction → ventricular rate ~150 bpm
Narrow QRS

Atrial Flutter — sawtooth F-waves in inferior leads, variable AV block

Typical counterclockwise atrial flutter — negative F-waves in II/III/aVF, positive in V1

4. ST-Elevation Myocardial Infarction (STEMI)

ECG hallmarks:

ST elevation ≥1 mm in ≥2 contiguous leads (≥2 mm in precordial leads)
Convex/tombstone morphology in hyperacute phase
Reciprocal ST depression in mirror leads
Evolving Q waves = transmural necrosis
Hyperacute T waves = earliest finding

Anterior STEMI (LAD territory — V1–V6, I, aVL):

Anterior STEMI — massive ST elevation V1–V6, tombstone morphology, LAD occlusion

Anterolateral STEMI (proximal LAD — V1–V6, I, aVL, reciprocal changes in II/III/aVF):

Anterolateral STEMI — convex ST elevation with reciprocal inferior depression

Inferolateral STEMI (RCA/LCx — II, III, aVF, V4–V6; reciprocal aVL depression):

Inferolateral STEMI — ST elevation inferior and lateral leads, reciprocal aVL depression

STEMI Territory Localization:

Leads	Territory	Artery
V1–V4	Anterior	LAD
I, aVL, V5–V6	Lateral	LCx
II, III, aVF	Inferior	RCA (80%), LCx (20%)
V1–V6 + I, aVL	Anterolateral	Proximal LAD / Left main
aVR elevation + diffuse ST↓	Global ischemia	Left main / 3-vessel disease

5. Global Ischemia / aVR Sign (Left Main / 3-Vessel Disease)

ST elevation in aVR (≥1 mm) + diffuse ST depression in multiple leads
Suggests severe hemodynamic compromise
Associated with cardiogenic shock

aVR elevation with diffuse ST depression — global ischemia pattern

6. Bundle Branch Blocks

Left Bundle Branch Block (LBBB)

Wide QRS ≥120 ms
Broad monophasic R in I, aVL, V5, V6
QS or rS pattern in V1 ("W" in V1, "M" in V6 — WiLLiaM)
Secondary ST-T changes discordant to QRS
New LBBB + chest pain = STEMI equivalent (Sgarbossa criteria)

LBBB — wide QRS 168 ms, QS in V1, broad R in lateral leads, discordant ST-T

Right Bundle Branch Block (RBBB)

Wide QRS ≥120 ms
rSR' ("rabbit ears") in V1–V2
Wide S wave in I, V5–V6 ("M" in V1, "W" in V6 — MaRRoW)
T-wave inversion in V1–V3

RBBB + left axis deviation (bifascicular block) — rSR' V1, wide S in I/V6

7. AV Blocks (Heart Blocks)

Comparison of all degrees:

AV blocks comparison — 1st, 2nd, 3rd degree illustrated with P-QRS relationships

Clinical series — progression from 1st-degree to complete heart block:

AV block progression — 1st degree → Mobitz II → Wenckebach → complete heart block

Type	PR Interval	P:QRS	QRS	Key Feature
1st degree	>200 ms (prolonged)	1:1	Narrow	Every P conducts
2nd degree Mobitz I (Wenckebach)	Progressive lengthening	>1:1	Narrow	Dropped beat after PR lengthening
2nd degree Mobitz II	Fixed (normal or long)	>1:1	Wide	Sudden dropped beat, no PR change
3rd degree (Complete)	AV dissociation	None	Wide or narrow	P and QRS independent

Complete heart block (3rd degree):

Complete heart block — full AV dissociation, independent P waves and ventricular escape rhythm

8. Ventricular Tachycardia (VT) & Ventricular Fibrillation (VF)

Ventricular Tachycardia (VT)

Wide QRS (>120 ms) tachycardia, rate >100 bpm (usually 150–250)
AV dissociation (P waves march through independently) — pathognomonic when seen
Fusion beats and capture beats confirm VT
LBBB-pattern VT with inferior axis → RVOT origin

Torsades de Pointes (TdP)

Polymorphic VT with twisting QRS axis around the isoelectric line
Preceded by long QT (QTc >500 ms) and "short-long-short" RR sequence
Causes: drugs (antiarrhythmics, antibiotics, antipsychotics), electrolyte disturbances

Torsades de Pointes — twisting polymorphic VT, wide irregular QRS, no P waves

Ventricular Fibrillation (VF)

Chaotic, disorganized deflections — no identifiable P, QRS, or T
No cardiac output — cardiac arrest

VF — NSVT → VF → 150J defibrillation → organized rhythm restoration

9. Left Ventricular Hypertrophy (LVH)

ECG criteria (any one meets threshold):

Criterion	Threshold
Sokolow-Lyon	S in V1 + R in V5 or V6 ≥35 mm
Cornell	R in aVL + S in V3 >28 mm (men) / >20 mm (women)
R in aVL	>12 mm alone

LVH strain pattern: ST depression + T-wave inversion in I, aVL, V5–V6 (discordant repolarization).

LVH — Cornell criteria, high R in aVL, deep S in V3, lateral strain pattern with T-wave inversions

Note: Obesity and horizontal cardiac position reduce ECG voltage sensitivity — a normal ECG does not exclude LVH. Echocardiography remains the gold standard.

10. Brugada Pattern

Type 1 (diagnostic): Coved ST elevation ≥2 mm in V1–V2 with negative T wave
Type 2 (saddle-back): Less specific
Associated with sudden cardiac death from VF in structurally normal hearts
Unmasked by fever, sodium channel blockers, cocaine, hyperkalemia

Brugada Type 1 — coved ST elevation V1, negative T wave, associated with COVID-19 fever

11. Myocarditis / Takotsubo (STEMI Mimic)

Diffuse ST elevation (not confined to one vascular territory)
Inferolateral pattern without coronary occlusion
Elevated troponin + normal coronaries on angiography

Myocarditis/Takotsubo — inferolateral ST elevation mimicking STEMI with reciprocal aVL changes

Quick-Reference Summary Table

ECG Pattern	Key Finding	Rate	QRS Width	Clinical Urgency
Sinus tachycardia	Regular, P before every QRS	>100	Narrow	Investigate cause
Sinus bradycardia	Regular, P before every QRS	<60	Narrow	Symptomatic? Consider pacing
Atrial fibrillation	Irregularly irregular, no P waves	Variable	Narrow	Rate/rhythm control, anticoagulate
Atrial flutter	Sawtooth F-waves, regular	~150 (2:1)	Narrow	Rate control, cardioversion
1st degree AV block	PR >200 ms, all P conduct	Normal	Narrow	Usually benign
Mobitz II	Fixed PR, sudden dropped QRS	Slow	Wide	Permanent pacemaker
Complete heart block	AV dissociation	Slow	Wide	Emergency pacing
STEMI	ST elevation + reciprocal changes	Normal/fast	Narrow	Emergency PCI
LBBB	Wide QRS, WiLLiaM pattern	Variable	≥120 ms	New = STEMI equivalent
RBBB	Wide QRS, MaRRoW pattern	Variable	≥120 ms	Often benign
VT	Wide-complex tachycardia, AV dissoc.	>150	>120 ms	Cardioversion/amiodarone
VF	Chaotic, no organized complexes	—	—	Immediate defibrillation
Torsades de Pointes	Twisting polymorphic VT, long QT	>200	Wide	Mg²⁺ IV, correct QT
LVH	High voltage, strain pattern	Normal	Narrow	Echo confirmation
Brugada Type 1	Coved V1–V2, ≥2 mm	Normal	Normal	ICD consideration

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