D R R O Z AZ I AN A AH M AD

D E PA R T M E N T O F P H Y S I O L O G Y
6/02/2018
GMT 107
 Learning Outcomes
1. What is ECG?
 What can be detectable in an ECG recording ?
2. Principles of ECG
3. ECG Leads
 Standard Limb leads (Bipolar & Unipolar)
 Chest leads (Unipolar)
4. . ECG Paper
 Normal ECG
 Waves identification, intervals and segments
 Calculation of Heart Rate
 Regular / Irregular rhythm
 Cardiac Axis
 Normal / deviation?
 Introduction
• Body is a good conductor (the body fluids
&electrolyte – conductive solutions)
• Electrical activity in the heart is conducted to all
parts of the body through body fluids
• The electrical potential generated by the heart can
be detected by placing electrodes on the surface of
the skin
 What is ECG?
• Electrocardiogram (ECG/EKG)
 ECG is a recording of the heart’s
electrical activities (representation of
the electrical events of the cardiac
cycle)
 Electro-cardio-gram
• Electro(electricity),cardio(heart), and gram
(recording)
• Electrocardiograph
– Refers to the machine that produces
electrocardiograms
 What are the detectable electrical activities in an ECG
recording ?

NOT ALL of the electrical activity in the heart is detectable by an

ECG.
ELECTRICAL ACTIVITY IN THE HEART

Recordable Not recordable

Depolarization of the atria Depolarization of the SA

(P wave) node

Depolarization of the Depolarization of the AV

ventricles (QRS complex) node

Repolarization of the Depolarization of the

ventricles (T wave) ventricular conduction system

•Repolarisation of the purkinje Repolarization of the atria

fibres (U wave) –NOT
ALWAYS
 Electrical (conduction) system of the Heart

-ve

+ve

© 2014 WebMD, LLC. All rights reserved.

https://emedicine.medscape.com/article/1922987-overview

SA node  AV node  Bundle of His  Bundle

branches (R&L) (ventricular septum)  Purkinje Fibres.

Principles of ECG

6
 Principles of Electrocardiography

1. The ECG works mostly by detecting and

amplifying the small electrical changes
on the skin when the heart muscle
"depolarizes /repolarizes" during each
heart beat.
2. The direction of deflection of the stylus of
the ECG depends on the direction of
current flow.
Electrical activity that travels towards a
positive end appears upright on an ECG and
is called a positive deflection.
Electrical activity that travels towards a
negative end appears inverted (downward) on
an ECG and is called a negative deflection
a. positive deflection

b. negative deflection
• The Greater the electrical current, the greater the
deflection and the higher the amplitude of the wave
• If the current flows for a longer time, the duration of the
wave will be greater
 ECG Leads
• Normal standard ECG consists of 12 leads that record
the electrical activity of the heart from different
orientations.
• Combination of these leads provides information about
heart size, orientation (axis) and cardiac electrical
conduction.
• There are two types of leads
1) Bipolar lead - has two different points on the
body
2) Unipolar lead - has one point on the body and a
virtual reference point with zero electrical
potential (located in the center of the heart)
 ECG Leads

Unipolar Bipolar

Limb leads Chest Leads

Augmented Limb Leads Chest Leads

•Lead aVR •V1,V2,V3,V4,V5,V6 Standard Limb Leads
•Lead aVL •Lead I
•Lead aVF •Lead II
•Lead III

10
BIPOLAR LEADS (I, II & III)
 these leads uses one positive electrode & one negative electrode.
 Bipolar leads look at the electrical activity between two electrodes — a positive
and a negative.

UNIPOLAR LEADS
 are the slow and steady electrodes that stay positive (+) and reference each
other to provide an accurate tracing.
Unipolar Augmented Limb Leads (aVR, aVL, aVF)
 The three unipolar limb leads (aVR, aVL, aVF) are positive electrodes that
augment the average of the other three limb electrodes to find the centre
terminal point of the heart (This is another reason why proper electrode
placement is so important. If placement is off, the centre terminal is off and the
tracing won’t be accurate to what is actually happening in the heart.)
Unipolar Precordial Leads (V1,V2,V3,V4,V5,V6)
 positive electrodes that measure electrical potential in reference to the center
terminal point.
 These are V1-V6 (V stands for voltage). Unlike the limb leads, the precordial
leads are close enough to the heart that they do not require any bonus
augmentation.
 The Standard Limb Leads
Einthoven's triangle
–Three limb leads roughly form an
equilateral triangle with the heart at the
center RA LA

Limb Leads Attachment 1 Attachment 2

(-) (+)
I right arm left arm
II right arm left leg
III left arm left leg

•These leads record electrical activity

along the frontal plane relative to the
heart. LL

Note
Electricity is the flow of electron around a circuit
from negative (-) to positive (+)
 The Einthoven's law states that
“the potential difference between the bipolar leads measured simultaneously will, at any given moment, have the values II
= I + III”.
Lead I +Lead III = Lead II
Einthoven's triangle in honor of Willem Einthoven who developed the electrocardiogram in 1901
 Augmented Limb Leads (Unipolar)
• There are three augmented limb leads
(aVR, aVL, aVF )
positive
Augmented Limb Leads electrode
(+)

aVF (augmented vector foot) left leg

aVL (augmented vector left) left arm
aVR (augmented vector right) right arm

• Unipolar leads - because there is a

single positive electrode that is referenced
against a combination of the other limb
electrodes
• Also record electrical activity along the
frontal plane relative to the heart
 Precordiol (Chest) Leads
•There are 6 unipolar chest leads.
•For all the leads, the (-) electrode is the sum of
the limb leads & the active electrode is placed in
different positions on the anterior chest wall

Leads Placement of the chest leads

V1 •4thintercostal space, right sternal border

V2 •4thintercostal space, left sternal border

V3 •Midway between V2 and V4

V4 •5thintercostal space, left midclavicular line

V5 •Level with V4, anterior axillary line

V6 •Level with V4,midaxillary line

 Orientations of the 12-Lead ECG
1. Bipolar limb leads (frontal plane)
• Lead I: RA (-) to LA (+) (Right Left, or lateral) I
• Lead II: RA (-) to LF (+) (Superior Inferior)
• Lead III: LA (-) to LF (+) (Superior Inferior) II III

2. Augmented Unipolar Limb Leads

(frontal plane)
• Lead aVR: RA (+) to [LA/LF] (-) (Rightward)
• Lead aVL: LA (+) to [RA/LF] (-) (Leftward)
• Lead aVF: LF (+) to [RA/LA] (-) (Inferior)
17
 3. Unipolar Precordiol (Chest) Leads (Horizontal Plane)

Leads Recorded electrical activities from

the
V1 & V2 Anterior aspect, septum & Right
ventricles (RV) of the heart
V3 & V4 Anterior aspect of the heart

V5 & V6 Left ventricle (LV) & lateral aspect

of the heart
 ECG Paper
Standard ECG Paper
–Bold (thick) lines = large squares 5 X 5 mm A

–Light lines = small squares- 1 X 1 mm B

–Standard paper speed and voltage

B
A
Horizontal axis = time Vertical axis = voltage

•Speed set at 25mm/sec
•Small square=0.04 sec.
•Large square=0.2 sec.
Voltage (mV)
•Voltage set at 10mm =
1mV
•Small square=0.1 mV
•Large square=0.5 mV
Time (sec)

Speed 1 small box =1mm

25mm = 1sec = 0.04 sec
1mm = 1x1 1 Large box = 5mm
25 = 0.04x5
= 0.04 sec = 0.2 sec
ECG PAPER
Waveform Measurements
 The waves of an ECG (Green line is
superimposed over the isoelectric line)

ECG Waves and Intervals

Isoelectric line the baseline on the ECG recording, perfectly straight and horizontal.
Wave above the isoelectric line is positive; below the line is negative
P wave the depolarization of the right and left atria
QRS complex right and left ventricular depolarization (normally the ventricles are
activated simultaneously)
T wave ventricular repolarization
U wave may visible, not always present, origin for this wave is not clear (The U
wave occurs when the ECG machine picks up repolarisation of the
Purkinje fibers)
 NORMAL ECG
A typical ECG tracing of a normal cardiac cycle consists of a P
wave, a QRS complex and a T wave.
Isoelectric line is the straight and horizontal line which is the
ECG baseline.
24
Guyton Textbook of Medical Physiology 11th edition
 NORMAL ECG (Lead II)

wave Electrical events Mechanical events

P Atrial depolarization Atrial systole
QRS Ventricular depolarization Atrial diastole and ventricular
systole
T Ventricular repolarization Ventricular diastole
 NORMAL ECG (Lead II)

wave shape Duration

(Normal range)
P Directed upwards, rounded 0.06-0.12 s
QRS Q wave is a negative deflection after the P wave and 0.06-0.10 s
before the R wave
R wave is the positive deflection after the Q wave,
directed upwards and pointed.
S wave is a negative deflection after R wave.
 Description
PR interval onset of atrial depolarization (P wave) to onset of ventricular depolarization
(QRS complex)
QRS duration duration of ventricular muscle depolarization

QT Interval Time of ventricular depolarization and repolarization

Prolonged QT intervals represents a prolonged time to repolarization

QT prolongation can occur as a consequence of ; Medication (anti-arrhythmics,

tricyclic antidepressants, phenothiazedes); Electrolyte imbalances; Ischemia

RR Interval Measure Heart Rate (HR)

 Intervals

Normal Duration (s)

Intervals
Average Range

PR interval 0.18 0.12 – 0.22

QRS complex 0.08 To 0.10

QT interval 0.40 0.28-0.43

 Segments

• PR segment
– The PR segment is flat
– Usually isoelectric segment between the end of the P wave
and the start of the QRS complex
ST segment
The ST segment represents the early part of ventricular
repolarisation
The ST segment is the line that from the end of the QRS complex
to beginning of the T wave.
Normally the ST segment is flat relative to the baseline (isoelectric
segment) - No electricity is flowing
 ST-Segment
• ST-Segment Elevation & Depression
– To be considered a significant elevation or depression the ST
must deviate at least 1 mm (1 small box) above or below the
baseline

ST-Segment Elevation
Most often seen with acute myocardial
injury or infarction
Others causes: Pericarditis, Hyperkalemia

ST-Segment Depression
Most often seen with acute myocardial ST depression
ischemia (MI) a suggestive of MI
Others causes: Hypokalemia, drug effects
(i.e. digitalis)
 A "Method" of ECG Interpretation

• When reading a 12-lead ECG tracing, it is desirable to follow

a standardized sequence of steps in order to avoid missing
subtle abnormalities in the ECG tracing
• A basic method to properly read an ECG, there are 6 major
sections in the "method" should be considered:
a) Measurements (?)
b) Rhythm Analysis
c) Conduction Analysis
d) Waveform Description
e) ECG Interpretation
f) Comparison with Previous ECG
 What is detectable in an ECG recording ?
• Not all of the electrical activity in the heart is detectable
by an ECG.

ELECTRICAL ACTIVITIES IN THE HEART

Recordable Not recordable
Depolarization of the atria Depolarization of the SA node

Depolarization of the ventricles Depolarization of the AV node

Repolarization of the ventricles Depolarization of the ventricular

conduction system

Repolarization of the atria

 Calculation of Heart Rate (HR)
• The normal range of resting heart rates: 60 - 100 bpm.
• HR < 60 bpm is consider slow (bradycardia)
• HR >100 bpm (tachycardia)

Methods to determine HR from ECG recording include:-

a. Irregular Heart rate

b. Regular Heart Rate (1 sec = 25mm ~ 25 small @ 5 big boxes, 60 sec = 1500 small @ 300 big boxes)
 Heart Rate Calculation

a) Big square between two consecutive R waves = 6

HR =(300 / 6) = 50 bpm
b) Small square between two consecutive R waves = 30
HR =(1500/30) = 50 bpm
 Rhythm
• To assess the cardiac rhythm accurately, a prolonged recording
from one lead is used to provide a rhythm strip.
• Lead II, which usually gives a good view of the P wave, is most
commonly used to record the rhythm strip.
• Normal sinus rhythm is the characteristic rhythm of the
healthy human heart. It is considered to be present if the heart
rate is in the normal range (60-100bpm), the P waves are
normal on the ECG followed by QRS complex, and the rate
does not vary significantly.
 Sinus rhythm
• The term “sinus rhythm” is
used when the rhythm
originates in the SA node
and conducts to the
ventricles.
• Cardinal features of sinus
rhythm
1. The P wave is upright in
leads I and II
2. Each P wave is usually
followed by a QRS
complex
3. The heart rate is 60‐100
beats/min
Sinus arrhythmia
• Sinus arrhythmia is a normal
physiological phenomenon,
most commonly seen in young,
healthy people
• It is the variation in the heart
rate that occurs during
inspiration and expiration.
• There is “beat to beat”
variation in the R‐R interval, the
rate increasing with inspiration
& reducing with expiration
• It is a vagally mediated
response to the increased
volume of blood returning to the
heart during inspiration.
 Respiratory Sinus arrhythmia
 Mechanism of increased in heart rate during inspiration

39
 BP=CO x TPR
BP= (SV x HR) x TPR
BP= [(EDV-ESV) x HR] x TPR

40
 Cardiac Axis
• The cardiac axis refers to the general direction
in which the heart depolarises. Depolarisation
wave
 SA node  AV node  Bundle of HIS  Purkinje fires to
complete an electrical cardiac cycle.

• The zero reference point looks at the heart

from the same viewpoint as lead I.
• An axis lying above this line is given a negative
number, and an axis lying below the line is
given a positive number.

Normal QRS axis is form around -30 to +90

degrees (to be in the normal quadrant)
More than -30 degree is called left axis deviation
More than +90 degree is called right axis
deviation.
 Cardiac axis
Cardiac Axis QRS axis between
Normal axis -300 and 1200
Left axis deviation -300 and -900
Right axis deviation 900 and 1800
Extreme Axis Deviation -900 and 1800

• There are several complementary

approaches to estimate QRS axis,
I. The Quadrant Method (Lead 1 & aVF)
II. The Vector Method

42
 The Quadrant Approach
• Examine the QRS complex in leads I and aVF to
determine if they are predominantly positive or
predominantly negative. The combination should place
the axis into one of the 4 quadrants below.
Negative in I, positive in aVF -- RAD
 The Vector Method
• To determine cardiac axis look at QRS of lead I, II,
III.
• The grid is simply a rearrangement of Einthoven's
triangle
• The QRS mean electrical axis can be calculated by
plotting the vectors of two of the three standard
leads (lead I, lead II and lead III)
Lead I + Lead III = Lead II

Lead I Lead II Lead III Axis

Positive Positive Positive/Negative Normal

Negative Positive Positive RAD

Positive Negative Negative LAD

45
 Normal Axis
Positive

Positive

Positive

Lead I Lead II Lead III Axis

Positive Positive Positive/Negative Normal

Negative Positive Positive RAD

Positive Negative Negative LAD

 Left Axis Deviation (LAD)
Causes : E.g :Normal variant; Left anterior fascicular block; Wolff-
Parkinson syndrome

Positive

Negative

Negative

Lead I Lead II Lead III Axis

Positive Positive Positive/Negative Normal

Negative Positive Positive RAD

Positive Negative Negative LAD

 Right Axis Deviation

Negative

Positive

Positive

Lead I Lead II Lead III Axis

Positive Positive Positive/Negative Normal

Negative Positive Positive RAD

Positive Negative Negative LAD

Thank you