A Systematic Approach to Electrocardiogram (EKG) Interpretation by Using 2 Mnemonics
Author: V. Dimov, M.D., Published in the Proceedings of the 3rd Annual Cleveland Clinic Perioperative Medicine Summit, CCJM.
This is a 2-step approach remembered by 2 mnemonics:
Step 1: Evaluate all elements of the EKG systematically: A RARE PQRST.
Step 2: Differential diagnosis. Look for diseases that may have caused the abnormalities noted in step 1: DR III EEE !
This systematic approach to reading electrocardiograms (ECGs or EKGs) works every time, just like a machine. By using it, you will not miss any major abnormalities in electrocardiograms (EKGs).
What is the meaning of the mnemonics?
A RARE PQRST:
Age, e.g. a 60-yo patient is likely have a different pathology from a 30-yo patient
Rate, e.g. fast or slow?
Axis, e.g. left or right?
Rhythm, e.g. regular or irregular?
Evaluate each EKG element as follows:
P wave, e.g. peaked or absent? PR interval – short or prolonged?
Q wave, e.g. deep Q wave? QT inerval – - short or prolonged?
R wave, e.g. tall? look at QRS complex width for RBBB or LBBB
ST segment, e.g. elevation or depression?
T wave, e.g. peaked or inverted? U wave?
DR III EEE:
Drugs , e.g. Digoxin, tricyclic antidepressants
Rhythm and rate abnormalities, e.g. AV block of 1,2,3 degree, AFib, SVT? Interval prolongation?
Infarct? Deep Q wave?
Infection, e.g. pericarditis
Enlargement, e.g. LVH, RVH, left or right atrium enlargement?
Electrolyte disturbances, e.g. hyperkalemia, hypokalemia, hypercalcemia,
Endocrine causes, e.g. hypothyroidism
How to use this approach in practice?
Look at the EKG and write down on a piece of paper:
A R A R E P Q R S T
D R I I I E E E
Circle the abnormalities you discover in step 1 — A RARE PQRST. Then, connect and try to explain these abnormalities by looking at the list of possible etiologies presented in step 2 — DR III EEE. That’s it!