ECG – GENERAL AND

NORMAL ASPECTS
 
ECG
 The recording of the heart’s electrical activity by several surface
electrodes placed in designated spots on the body is called an
electrocardiogram.
 The investigation is called electrocardiography.

 The apparatus is called electrocardiograph (Einthoven – 1903).

 The galvanometer quantifies electrical potential variations and

„translates” potential variations in a graphic mode;
 potential differences => waves (= deflections)
 no potential differences => isoelectrical line
 The millimetric paper is rolled out with a speed of
25 mm/s, therefore 1mm in horizontal line is 0.04’’(seconds);
 calibration button: 1mV = 10 mm (1 mm=0.1mV)
THE SURFACE ELECTRODES

 for frontal leads

 right arm – Red

 right foot – Black
 left arm – Yellow
 left foot – Green
THE SURFACE ELECTRODES
 for precordial leads

 V1 – intercostal space IV, right parasternal

 V2 – intercostal space IV, left parasternal

 V3 – between V2 andV4

 V4 – intercostal space V mid-clavicular line

 V5 – intercostal space V anterior axillary line

 V6 – intercostal space V mid-axillary line

 V7 and V8 intercostal space V posterior axillary

line and the line that goes through inferior angle

of the scapulae (optional)
THE SURFACE ELECTRODES FOR
PRECORDIAL LEADS
 FRONTAL BIPOLAR LEADS
 Both electrodes used for each derivation are exploring electrodes.

 Lead I uses the electrode on left arm as a (+) electrode and the electrode on the
right arm as a negative electrode. LI axis is the imaginary line that unites the 2
electrodes, and is parallel with the ground. In the middle of the segment that
unites the 2 electrodes is considered the point 0 (electric) of LI axis. From point 0
of the axis to left arm electrode is the positive segment of the axis, from point 0
to right arm electrode is the negative part of the axis.

 Lead II uses the electrode on left leg as a (+) electrode and the electrode on the
right arm as a negative electrode. LII axis is the imaginary line that unites the 2
electrodes. In the middle of the segment that unites the 2 electrodes is
considered the point 0 of LII axis. From point 0 to left leg electrode is the
positive segment of the axis, from point 0 to right arm electrode (the negative
electrode) is considered the negative part of the axis.

 Lead III uses the electrode on left leg as a (+) electrode and the electrode on the
left arm as a negative electrode. LIII axis is the imaginary line that unites the 2
electrodes. In the middle of the segment that unites the 2 electrodes is
considered the point 0 of LIII axis. From point 0 to left leg electrode is the
positive segment of the axis, from point 0 to left arm electrode is considered the
negative part of the axis
FRONTAL BIPOLAR LEADS
FRONTAL UNIPOLAR LEADS (AUGMENTED
LEADS)

 An unipolar lead uses an exploring electrode and

a so-called indifferent electrode
 The indifferent electrode is placed in a artificial

point of 0-electric created by the apparatus; this

artificial point 0 is called „central terminal” and
sits theoretically in the center of the electric field
of the heart.

• aVF (F = Left Foot)

• aVR (= Right arm)
• aVL (= Left arm)
 aVR lead has the exploring electrode on right arm and the other
electrode in central terminal so in the point 0 of the heart’s electric
field. aVR axis is the imaginary line that unites these two electrodes.
The sense of aVR is from central point of heart’s electric field towards
up and right. From point 0 towards exploring electrode is the positive
segment of the axis; the opposite part is the negative part.

 aVL lead has the exploring electrode (+) on left arm and the other
electrode in central terminal, in the point 0 of the heart’s electric field.
aVL axis is the imaginary line that unites these two electrodes. The
sense of aVL axis is from central point of heart’s electric field towards
up and left . From point 0 towards exploring electrode is the positive
segment of axis; the opposite part is the negative part.

 aVF lead has the exploring electrode (+) on left foot and the other
electrode in central terminal so in the point 0 of the heart’s electric field
(= central point of the electric field of the heart). aVF axis is the
imaginary line that unites these two electrodes. The sense of aVF axe is
from up towards down, vertically. From point 0 towards exploring
electrode is the positive segment of axis; the opposite part is the
negative part.
• aVF, aVL and aVR are united in the
central point of electric field and form
angles of 60°
• By combining all six frontal axes, the
hexa-axial system is obtained.
• In this system the axes form angles of
30° between them and there are 3 pairs
of perpendicular axes: LI with aVF,
LII with aVL and LIII with aVR.
• The sense of the axis is toward positive
= towards the positive electrode for
bipolar derivation and towards
exploring electrode for unipolar
derivation.
• The sense of the axis (and the positive
segment) is marked by an arrow.
• LI and aVL are called left or lateral
leads;
• LII, LIII and aVF are called inferior
leads.
THE HEXA-AXIAL SYSTEM
HORIZONTAL PLANE LEADS =
PRECORDIAL LEADS
 V1, V2, V3, V4, V5, V6
 *V3R, V4R, V5R = that use points situated

symmetrical to V3, V4 and V5 points, on the

right side of the thorax; they are used if a
myocardial infarction of the right ventricle is
suspected
 **V7, V8 and V9 – the exploring electrodes are

situated in left fifth intercostal space: in the

posterior axillary line-V7, inferior angle of
scapula line-V8 and paravertebral-V9; they are
used if a myocardial infarction of the posterior
wall is suspected.
HORIZONTAL PLANE LEADS

V1 and V2 are considered right precordial leads - they “see” the right
ventricle and the septal surface of the heart (interventricular septum);
V3 and V4 are considered anterior precordial leads – they “see” anterior
wall of the left ventricle and the apex
V5 and V6 are considered left (or lateral) precordial leads – they “see” the
lateral wall of the left ventricle
NORMAL DEPOLARIZATION
 It is generated first in the sino-atrial node (SA) = the cardiac pace-maker
– which it is situated in the right atrium (RA).
 The depolarization is propagated to and by the atrial myocardial cells

(velocity = 1 m/s).
 Then the depolarization arrives at AV node (velocity = 0.2 m/s); the AV node

is normally the only access for electrical impulses between atria and ventricles,
but besides this, it also has the role of delaying the spread of depolarization
from atria to ventricles (so the ventricles are able to contract after the atria).
 From AV node the depolarization is spread to His bundle and His bundle

branches, to Purkinje cells (here the speed is very high = up to 4m/s)

and then to ventricular cells.
 Because they are in the vicinity of Purkinje fibers, the first myocardial cells

that are depolarized in the ventricular muscle are the subendocardial

cells.
 Then the electrical impulse travels in the middle zone of myocardial muscle

and finally arrives in the subepicardial region.

Because the SA node has
the faster auto activation
rate, it becomes the leader,
the pace-maker.

 ***Other cells than those of sinoatrial node can exhibit in certain

situation pace-maker activity but they have a normally slower activity:
AV node cells, cells of His bundle and cells of its ramifications.
 SA node cells have the normal capacity to auto depolarize, usually at 60 to 100
times per minute.
 AV node can achieve a spontaneous auto activation with a frequency of 50-
40/minute,
 Purkinje fibers a frequency of 25/minute.  
REPOLARIZATION

 Unlike depolarization, the repolarization is not propagated through the

conduction tissue, but from one miocardic cell to another. It is a slower
process, but not a passive one (it consumes energy). Also, repolarization is
not a mirror- image of depolarization.
 Atrial repolarization is a slow process and doesn’t involve an important

mass of cells so it isn’t usually observed in ECG.

 Ventricular repolarization, although also a slower process than ventricular

depolarization, involves a greater number of myocardial cells and has a

graphic expression.
 Although it may seem logical that the first cells that are depolarized should

be the first cells to be repolarized, it isn’t what happens in normal

situations and that is because the subepicardial cells and subendocardial
cells have different potassium channels;
 potassium channels involved in repolarization of subepicardial cells

are faster than those of subendocardial cells therefore

repolarization begins in subepicardial regions and ends in
subendocardial regions.
CARDIAC VECTORS
 are oriented from (-) electric charge towards (+) electric charge
 The resultant vector of the whole atrial depolarization;
 the right atrial (RA) depolarization vector;
 the left atrial (LA) depolarization vector.

 Septal depolarization vector

 Depolarization vector of the lateral wall of the right ventricle

(RV);
 Apex depolarization vector

 Depolarization vector of the lateral wall of the left ventricle

(LV)
 Basal depolarization vector

 The resultant vector of ventricular repolarization (= the

electric axis of the heart)

RELATIONSHIP OF CARDIAC VECTORS
WITH DERIVATION AXES:
 A lead will “see” a vector by the projection of this particular vector
on that lead. The vector is translated in the axial system (of the
frontal plane or of the horizontal plane) with its origin point in the 0
point of the system. From the tip of the vector a perpendicular line
to an axis is then drawn.
 If the vector projects on the positive part of the axis it will determine

a positive wave (= a wave situated above the isoelectric line);

 If the vector is projected on the negative segment of the axis a

negative deflection (= a wave situated below the isoelectric line) is

registered on ECG course.
 The magnitude of the projection depends on the angle between the

vector and the lead:

a parallel vector determines the biggest projection;
 a perpendicular vector determines the smallest projection (a point) or an
equiphasic complex.
NORMAL ATRIAL DEPOLARIZATION – THE P WAVE

 The aspect of P wave depends on how the atrial

depolarization vector is projected on the respective lead.
 In frontal plane:

Atrial depolarization vector; RA and LA The atrial depolarization vector projects on positive parts of DI, aVF, DII (evidentiated
depolarization vectors by positive P waves in these leads); and on the negative segment of aVR (the P wave
is negative in aVR).
  In horizontal plane:

In V1 and V2 the normal P wave is frequently biphasic with a In V3, V4, V5, V6 the normal P wave is positive.
first positive phase that is the projection of RA depolarization
vector and a second negative part that is the expression of LA
depolarization.
NORMAL VENTRICULAR
DEPOLARIZATION – THE QRS
COMPLEX
 The first areas that undergo depolarization are the
subendocardial ones, so ventricular depolarization occurs
from the subendocardial regions to the subepicardial
regions.
 Septal depolarization vector is oriented from left to right
slightly down and from posterior to anterior.
 Apex depolarization vector is oriented from right to left
and downwards
 Depolarization vector of the lateral wall of the left
ventricle (LV) is oriented from right to left and from
anterior to posterior.
 Basal depolarization vector is oriented from right to left,
upwards and from anterior to posterior.
 There is a physiological asynchronism in ventricular
depolarization: RV depolarization begins and ends before LV
depolarization
NORMAL VENTRICULAR
REPOLARIZATION – THE T WAVE
 The repolarization process doesn’t start from endocardial areas but
from epicardial areas (these cells have a shorter action potential due
to high permeability K channels)
 Because repolarization starts in subepicardial cells, these cells are the
first to become electropositive, while subendocardial cells are still
electronegative.
 The repolarization vectors are therefore oriented from inside (-) towards
outside(+).
 The repolarization vector
is oriented from up-right
to down-left
(opposite to the direction
of the repolarization front)
NORMAL ECG WAVES:
 P wave
 in frontal leads - positive, with the exception of aVR (where is negative),
with maximum height in D II
 in precordial leads
 V1, V2 = positive or equiphasic

 (with first complex positive) or negative

 positive in V3, V4, V5, V6

 QRS complex
 in frontal leads: positive (usually) with the exception of aVR
 in precordial leads: in V1 aspect rS and in V6 aspect qRs

 T wave – usually consistent with QRS complex

 in frontal leads: positive (usually) with the exception of aVR
 in precordial leads usually positive (exception: in children, adolescents, young
adults when it may be negative in V1, V2 and even V3)
 U wave – visible sometimes after T wave is caused by stretch mediated
depolarization of the ventricular myocardia during diastolic filling.
ECG I
ECG II
ECG III