Electrocardiography

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R wave
Electrocardiography
- Procedure used to record electrical activity of the human heart Apex Depolarization

QRS Complex
ST Segment
Ventricular
Depolarization Plateau S wave

Posterobasal
PR Interval Depolarizatio

Atrial Depolarization
+
AV Nodal Delay

T wave
P wave
Ventricular
Atrial Repolarization
Depolarization Q wave
QT Interval

Interventricular Septum
PR Segment Ventricular Depolarization
Depolarization
+
Ventricular Repolarization
AV Nodal Delay
- Fewer gap junctions
- Smaller diameter fibers U wave

Slow repolarization of the papillary muscles. If the height of the T wave is equal
to the height of the U wave, it may indicate Hypokalemia in the patient.

Impulse Conduction
Rule #1: Depolarization following direction of impulses = Positive Deflection ^
Direction of Impulses
Rule #2: Depolarization away from direction of impulses = Negative Deflection v
 Downward
Rule #3: Repolarization following direction of impulses = Negative Deflection v
 Right to Lef
Rule #4: Repolarization away from direction of impulses = Positive Deflection ^
- SA Node generates an impulse
o Atrial Depolarization occurs
 P wave
 Depolarization direction
 Downward Follows Rule #1
 Right to lef
- Impulse is transmitted to the AV node
o AV Nodal Delay
 PR Segment
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 Isoelectric line (no electrical activity noted)

- Atrial Repolarization occurs (Unseen in the ECG)
Atrial Muscle
o Repolarization Direction
 Downward Follows Rule #3 The first part to Depolarize will
 Right to lef be the first part to Repolarize.
- Impulse is transmitted to the Ventricular Conduction System
o Ventricular Depolarization Occurs
Ventricular Muscle
 QRS Complex
 Q Wave The first part to Depolarize will
o Interventricular Septum Depolarization be the last part to Repolarize.
 Depolarization direction
 Downward Follows Rule #2 The last part to Depolarize will
 Lef to Right be the first part to Repolarize.
 R Wave
o Cardiac Apex Depolarization
 Depolarization Direction
 Downward Follows Rule #1
 Right to Lef
 S Wave
o Posterobasal Depolarization
 Depolarization direction
 Upward  Follows Rule #2
- Ventricular Repolarization occurs
o Q Wave
 Depolarization direction
 Upward  Follows Rule #4

Automatic Cells
- Sinoatrial (SA) Node
o Node of Keith and Flack
o Primary pacemaker of the heart
o Suppresses automaticity of other automatic cells
 Overdrive suppression
- Atrioventricular (AV) Node
o Node of Kent and Tawara
o AV Nodal delay
o Slow velocity of impulse conduction (0.05 m/s)
- Purkinje system
o Bundle of His
o Lef and Right bundle branch
o Purkinje Fibers

ECG Procedure
- Types
o Resting ECG
 Most common procedure done
 Remove all metal items
 Usually uses all leads
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o Exercise ECG / Stress test / Treadmill test

 Detects the heart’s electrical activity changes during activity
 At least 3 chest electrodes are used
- Application of electrode gel
- Leads
o Method discovered by Dr. Einthoven
o Ground Lead
 Eliminates non-cardiac electrical activities
 Right leg (Black)
o Bipolar Limb Leads
 Lead I
 Records electrical activities in the base of the heart
 Right Arm (Red) to Lef Arm (Yellow)
 Lead II
 Records electrical activities from the base going to the apex on right side of the heart
 Follows cardiac vector
 Right Arm (Red) to Lef Leg (Green)
 Lead III
 Records electrical activities from the base going to the apex on lef side of the heart
 Lef Arm (Yellow) to Lef Leg (Green)
o Unipolar Limb Leads
 aVR
 Center to the right uppermost part of the heart
 aVL
 Center to the lef uppermost part of the heart
 aVF
 Center to the apex of the heart
o Unipolar Chest Leads
 V1 4th Intercostal Space, Right Sternal Border
 V2 4th Intercostal Space, Lef Sternal Border
 V3 In between V2 and V4
 V4 5th Intercostal Space, Lef Mid Clavicular Line
 V5 5th Intercostal Space, Lef Anterior Axillary Line
 V6 5th Intercostal Space, Lef Mid Axillary Line
o Esophageal Leads
 V7, V8
 Rarely used
 Most posterior portion of the heart
 Patient is asked to swallow the leads

- Body fluids transmit conduction from heart

- Einthoven’s Equation
o (Lead II) = (Lead I)+ (Lead III)
 Lead II shows the tallest recording in the ECG
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ECG Reading
- Vertical Reading
5mm = 0.2 s
o Amplitude (millivolts)
- Horizontal Reading
o Time (seconds)
1mm = 0.1 mv

5mm = 0.5 mv 1 Hash Mark

Equivalent to 3 seconds
(15 big boxes)

1mm = 0.04 s

- Interpreting the Heart Rate

o Only for ECG readings with a regular rhythm
o Count the number of small boxes in between the RR intervals
o Multiply number of small boxes by 0.04 seconds

60 seconds
Heart Rate =
RR Interval

o Example 60 seconds .
12 x 0.04 = 0.48 = 125 bpm
0.48 seconds
1 5 10 12

Shortcut! (Only for exact RR Intervals)

- 5 small boxes (1 big box) = 300
- 10 small boxes (2 big boxes) = 150 Normal Duration
ECG Intervals
- 15 small boxes (3 big boxes) = 100 Common Range
- 20 small boxes (4 big boxes) = 75 PR Interval 0.18 s 0.12 – 0.21 s
- 25 small boxes (5 big boxes) = 60
- 30 small boxes (6 big boxes) = 50 QRS Interval 0.08 s 0.08 – 0.10 s
- 35 small boxes (7 big boxes) = 43 QT Interval 0.40 s 0.40 – 0.43 s
- 40 small boxes (8 big boxes) = 37 ST Interval 0.32 s 0.12 – 0.21 s
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Cardiac Abnormality Detection in ECG

- Arrhythmias
o Bradycardia
 RR < 60 bpm
o Tachycardia
 RR > 100 bpm
o Pacemaker abnormalities
o Heart Blocks
 1st degree
 Prolonged PR Interval
 2nd degree
 PQRS – P – PQRS (2:1 / 3:1)
 3rd degree
 P waves found in many parts
- Myocardial Ischemia / Injury / Infarction
o Ischemia
 Depressed T wave
T↓schemia (Tischemia)
o Injury
Injur↑ST (injuryST)
 ST segment elevation
infarQtion (infarction)
o Infarction
 Pathologic Q wave
- Hyperkalemia
o T wave
- Hypokalemia
o Prominent U wave
- Hypocalcemia
o Narrow QRS Interval

Vectocardiography
- Determination of the electrical axis of the heart
- Mean cardiac vector (angle) indicates the average direction of current flow in the heart
o Normal (Local)
 0 to 90° Deviation from the normal axis
o Normal (Western) may indicate Cardiomegaly

 -30 to +110°
o Average / Common Vector / Common Axis
 59°
- 2 methods
o Method 1
 Lead I and aVF
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o Method 2
 Lead I, Lead II and Lead III