Introduction to the 12 Lead EKG

12 Leads are Universal in Their Placement:

Lead I aVR V1 V4
Lead II aVL V2 V5
Lead III aVF V3 V6

Three Principles to Learn:
When a wave of depolarization moves toward a + electrode of any lead, an
upright wave is inscribed.
When a wave of depolarization moves away from a + electrode of any lead, a
negative wave is inscribed.
When depolarization moves perpendicular to the + electrode of any lead,
either a biphasic or line will be inscribed.
Review: Conduction Systems of the Heart
SA Node:Initiates a normal rhythmic electrical activity. Wave of
depolarization moves through the atria. The SA node is very small and its
electrical activity is not seen on the ECG. A P wave is seen when the atria
depolarize.
AV Node:Delays electrical activity before it proceeds into the ventricles.
This normal delay allows time for the atria to depolarize when the
ventricles are still in diastole.
Junctional Bundle:Conducts impulse from atria into the ventricles.
Electrical impulse travels into ventricular conduction system via the
Junctional bundle and down the bundle branches.
Purkinje fibersenter the myocardial cells and conduct the electrical
impulses throughout the ventricles.
QRS Complex (Normally <.12 seconds)
First wave of complex is negative/below isoelectric line and called a q
wave.
Must be first wave of complex and must be negative and small.
Amplitude (normal q wave) is less than one fourth height of its R-wave.
R waveis always positive (above isoelectric line). No such thing as a
"negative R-wave".
S waveis a negative deflection following the R wave.
T waverepresents ventricular repolarization. Normal T waves are in the same
direction as their complex. Normal T wave is asymmetrical and it peaks
toward the end, instead of the middle. Normal T: in frontal plan <= 5mm, in
precordial plane <= 10mm tall.
ST Segmentis measured from the end of complex to the beginning of T wave.ST
is the beginning of ventricular repolarization.
Normal STis on the isoelectric line or no more than 1mm above or below
isoelectric line.
Elevated STis more than 1mm above isoelectric line.
Depressed STis more than 1 mm below isoelectric line.
PRI (normal PRI 0.12 - .20 seconds)
Normal PRI is measured from beginning of the P to the beginning of the complex.
This measurement represents the time it takes for a wave of depolarization to
spread through the atria, AV node, and AV junction.
Paper and Voltage
Each small box on the horizontal line represents 0.04 seconds. Each large box on

the horizontal line represents 0.20 seconds. There are five small boxes in one
large box. Each small box on the vertical line equals 0.1 millivolts. 10 small
boxes = 10 mm tall.
Leads, Lead Placement, Precordial Leads
The activity of the heart produces electrical potentials, which can be measured
on the surface of the body.
Lead I, II, III:The three limb leads are placed across the heart. The heart,

an electrical source, is the center for Einthoven's Triangle: forming a
triaxial reference system.

The frontal leads are augmented vector leads: leads that reflect the
potentials of the right arm, left arm, and left leg are called VR, VL, aVR,
AVL, and aVF.
Precordial leads
Surface view of leads
Coronary Artery Distribution
Right coronary artery: supplies right heart, in the ventricle it supplies
inferior surface, 2/3 posterior and part of the left lateral wall.
Left coronary arterybifurcates into two main branches:
Left circumflex (LCX):supplies lateral wall of the left ventricle and
part of the posterior wall.
Left anterior descending coronary (LAD):supplies anterior wall of the
left ventricle, the intraventricular septum, part of the lateral wall of

the left ventricle - referred to as the "sudden death artery".
Review of the Leads
Inferior Leads
RCA supplies the inferior wall of the ventricle.
MI's involving inferior surface of the heart will be seen in leads II,
III, and aVF.
Lateral Leads
Leads I, aVL, V5, V6.
Lateral infarctions are usually associated with obstruction of the left
circumflex artery.
Septum and Anterior Leads
Intraventricular septum - leads V1 and V2.
Anterior Wall - V2, V3, V4.
Anterior infarctions are usually associated with occlusion of the left
anterior descending branch of the left coronary artery.
Myocardial ischemia, injury, and acute infarction
The three EKG changes are:
elevated ST segments.
inverted T waves.
pathological Q abes.
Elevated ST segments (myocardial injury)
Normal ST segments are in the isoelectric line or no more than 1mm above

or below it.
An abnormal electrical charge is produced on membrane of myocardial cell

resulting in abnormal current flow causing an elevation of ST segment.
Myocardial injury causes elevation of ST segments over affected area of
the ventricle. ST segments changes are the earliest indication on EKG.
ST segment changes occur within a few hours or a few days and should
return to the isoelectric line within 2 weeks.
Inverted T waves (myocardial ischemia)
Myocardial ischemia causes symmetrical inversion of the T wave. T wave
abnormalities reflect a change in ventricular repolarization.
As the ST segment begins to return to the isoelectric line, the
symmetrical inversion of the T wave appears.
The T wave will become progressively deeper as the ST segment returns to

the isoelectric line.
Pathological Q waves (myocardial infarction)
Normal Q waves are small, less than 1 mm deep or wide and one fourth the

height of their R wave.
Pathological Q waves usually develop when ST segments are elevated and
appear several hours or days after the clinical manifestations of the
MI.
Abnormal Q must be one small square (0.04 sec) wide and greater than
one-third of QRS height in Lead III.
Myocardial infarction causes pathological Q waves over the affected area

of the ventricle. The age of the infarction can be determined.
Q waves only - old infarction
Q waves with elevated ST segments (with or without T wave inversion)

- acute infarction
Q waves with inverted T waves - age undetermined.
Acute Infarction on EKG
Transmural MI- involves the full thickness of myocardium
Nontransmural MI- does not involve the full thickness of myocardium. Also
called subendocardial. Changes occur in ST-T wave.
EKG changes in transmural MI occur both in depolarization -q wave and
repolarization -ST-T.
Four phases of acute MI on EKG:
hyperacute phase- ST elevation and upright T waves. Occurs in first few
hours and lasts 1-6 weeks. ST elevation beyond 6 weeks - suspect
ventricular aneurysm.
fully evolved phase- after hours or days. Deep T waves and appearance of

diagnostic q waves.
resolution phase- T waves return to normal within weeks to months.
stabilized chronic phase- q waves remain permanent

Bibliography
Goldberger AL, Golderber E: Clinical Electrocardiography: simplified
approach, ed 5, Chicago, 1994, Mosby.
Norman, Ann E: 12 Lead Interpretation: a self teaching manual, St. Louis,
1992, McGraw-Hill, Inc.
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