Last edited: 9/25/2021

6. EKG BASICS
Cardiovascular | EKG Basics Medical Editor: Dr. Ana Guerra

OUTLINE II) DEFLECTIONS BASED ON LEAD II

I) BASIC CONCEPTS (1) P-wave

II) DEFLECTIONS BASED ON LEAD II
SA node fires and sends positive electrical signals
III) LEADS
IV) APPENDIX towards AV node
V) REVIEW QUESTIONS o → “Positive” vector is created and it points towards
VI) REFERENCES positive electrode of lead II
o → Upward deflection on EKG.

I) BASIC CONCEPTS

(A) DEFINITION
The electrocardiogram (ECG/EKG) is a graphic expression
of the electric activity of the heart, and is a useful test to
diagnose several cardiac pathologies. (Saturno, 2017)

(B) 12 LEADS
Each view from the heart activity is described as a “lead”.
Bipolar leads: I, II, III.
Augmented unipolar leads: aVF, aVR, aVL.
Precordial (chest) leads: V1-V6.

Figure 1.4. P-wave: Electrical signals are sent from SA node to

AV node.

(2) PR segment
AV node receives positive electrical signals from SA node
but conducts electrical signals very slowly;
o it doesn’t create a net vector
o → No deflection
o → Straight/isoelectric line on EKG.

Figure 1.1. 12 leads [cables y sensores]

(C) ELECTRIC CONDUCTION OF THE MYOCARDIAL

TISSUE
(1) Imagine a conduction of positive charge through
the myocardial tissue
If positive charge moves towards
negative charge
o it causes a downwards
deflection on EKG.
If positive charge moves towards
the positive electrode
o it causes an upwards Figure 1.2. Conduction of
positive charge.
deflection on EKG. Figure 1.5. P-R segment.
(2) Imagine a conduction of negative charge through
the myocardial tissue
Clinical Note: Heart Block
If negative charge moves 1st degree heart block
towards negative charge o Slow AV conduction
o it causes an upwards
2nd degree heart block
deflection on EKG.
o Only some action potential is being conducted
If negative charge moves towards
3rd degree heart block
the positive electrode o No AV conduction
o it causes a downwards Figure 1.3. Conduction
of negative charge.
deflection on EKG.

EKG BASICS CARDIOVASCULAR PHYSIOLOGY: Note #6. 1 of 5

(3) Q-wave (6) ST segment
AV node conducts positive electrical signals into bundle The entire ventricular myocardium is still depolarized and
of His and down bundle branches hasn’t gone into a repolarization state yet.
o → The left bundle branch causes positive electrical o → There is no more movement of positive electrical
signals to move from left to right signals
o (Depolarizing the septum only from the left bundle o → No electric vector
branch) o → No deflection
o → A “positive” vector pointing slightly towards the o → Isoelectric line on EKG.
negative electrode is created
o → Small negative deflection on EKG.

Figure 1.6. Q-wave.

Clinical Note: Deep Q-wave

When deep (>2 mm) and wide (>0.04 seconds) or Figure 1.9. ST segment.
>25% of the QRS.
o → Previous myocardial infarction.
Clinical Note: Acute ST elevation myocardial
infarction (STEMI)
(4) R-wave V1-V2
o Septal.
Bundle branches conduct positive electrical signals into
V3-V4
purkinje fibers o Anterior.
o → More positive electric signals are conducted to the
thicker left ventricle in comparison to the right I, aVL, V5-V6
ventricle o Lateral.
o → Large net “positive” vector pointing slightly more to II,III, aVF
the left ventricle apex and positive electrode o Inferior.
o → Large positive deflection on EKG.

(7) T-wave
The ventricular myocardium starts repolarizing
o → Negative electrical signals move from the outer
layers of myocardium to inner layers / left ventricle is
much thicker than right ventricle causing more
negative electrical signals
o → Flow of negative electrical signals move towards
base of heart
o → “Negative” vector pointing to negative electrode is
Figure 1.7. R-wave. created
o → Upward deflection on EKG.

(5) S-wave
The purkinje fibers conduct positive signals through the
ventricles
o → “Positive” vector pointing up towards base of heart
neat negative electrode is created
o (Indicative of the depolarization at the bases of the
ventricles)
o → Small negative deflection on EKG.

Figure 1.10. T-wave

Clinical Note: Inverted T-wave

Figure 1.8. S-wave. Considered abnormal if deeper than 1.0 mm
o Sign of myocardial ischemia.

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 III) LEADS
(A) BIPOLAR LIMB LEADS
• Look at the heart in a frontal plane.
• They measure the potential difference between two
points.
(1) Lead I
Negative electrode at Right arm.
Positive electrode at Left arm.
Leads look at heart from positive to negative lead.
Looks at heart from left lateral side.
Figure 1.11 Lead I
(2) Lead II
Negative electrode at Right arm.
Positive electrode at Left Leg.
Leads look at heart from positive to negative lead.
Looks at heart from inferior view.
Figure 1.12. Lead II
(3) Lead III
Negative electrode at Left arm.
Positive electrode at Left Leg.
Leads look at heart from positive to negative lead.
Looks at heart from inferior view.
Figure 1.13 Lead III
Eithoven Triangle and Law
I + III = II
EKG BASICS
(B) AUGMENTED UNIPOLAR LIMB LEADS
• Look at the heart in a frontal plane.
They measure the potential heart from a single point.
EKG machine creates these specialized electrodes.
(1) AVR
Negative electrode at Left arm.
Negative electrode at Left leg.
Positive electrode at Right arm.
Net vector points between left arm and left leg towards
right arm.
Looks at right side of heart.
Figure 1.14. aVR Lead [cables y sensors].
(2) AVL
Negative electrode at Right arm.
Negative electrode at Left leg.
Positive electrode at Left arm.
Net vector points between Right arm and Left leg towards
Left arm.
Looks at heart from left lateral side.
Figure 1.15. aVL Lead [cables y sensores].
(3) AVF
Negative electrode at Right arm.
Negative electrode at Left arm.
Positive electrode at Left leg.
Net vector points between Right arm and Left arm
towards Left leg.
Looks at heart from an inferior view.
Figure 1.16. aVF Lead [cables y sensores].
CARDIOVASCULAR PHYSIOLOGY: Note #6. 3 of 5
 (C) PRECORDIAL (CHEST LEADS) (2) Electrodes
Look at the heart in a horizontal plane. Contains only a positive electrode placed on chest wall.
It helps us localize pathologies like myocardial infarctions V1&V2: Detects electrical activity from anterior wall of
both ventricles.
(1) Placement of leads
V3&V4: Detects electrical activity Interventricular septum
V1: Right 4th intercostal space, parasternal line. and anterior wall of left ventricle.
V2: Left 4th intercostal space, parasternal line. V5&V6: Detects electrical activity from Apex.
V3: Between V2 and V3.
V4: Left 5th intercostal space, midclavicular line.
V5: Left 5th intercostal space anterior axillary line.
V6: Left 5th intercostal space mid axillary line.

Figure 1.18. Electrodes.

Figure 1.17. Placement of Leads.

IV) APPENDIX

Figure 1.19. Complete sequence of Lead II.

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 V) REVIEW QUESTIONS VI) REFRENCES

Which of the following is the only lead that can see

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a. III guide-with-illustrations
b. aVR ● Cardiología / [coordinador y autor] Guillermo Saturno Chiu. – 1a
edición. – Ciudad de México: Editorial El Manual Moderno, 2017.
c. V3 ● Le T, Bhushan V, Sochat M, Chavda Y, Zureick A. First Aid for
d. aVF the USMLE Step 1 2018. New York, NY: McGraw-Hill Medical; 2017
● Mancini MC. Heart Anatomy. In: Berger S Heart Anatomy. New
York, NY: WebMD.https://emedicine.medscape.com/article/905502-
Which of the following structures is responsible for overview.
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a. AV node https://embryology.med.unsw.edu.au/embryology/index.php/Cardiov
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b. Bundle of His
● Rosen IM and Manaker S. Oxygen delivery and consumption.
c. SA node In: Post TW, ed. UpToDate .Waltham, MA:
d. Purkinje fibers UpToDate.https://www.uptodate.com/contents/oxygen-delivery-and-
consumption#H4.
● McCorry LK. Physiology of the Autonomic Nervous System. Am
This graphic represents the complete depolarization J Pharm Educ .2007; 71(4): p.78. doi: 10.5688/aj710478.
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● Leslie P. Gartner, James L. Hiatt. Color Textbook of Histology.
b. PR segment New York (NY): Grune & Stratton Inc.; 2006
c. ST segment ● U. S. National Institutes of Health, National Cancer Institute. NIH
d. S-wave SEER Training Modules - Classification & Structure of Blood
Vessels.
https://training.seer.cancer.gov/anatomy/cardiovascular/blood/classi
Which of the following is represented as a negative fication.html.
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a. V1 ● Klabunde RE. Hemorrhagic Shock.
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● Kaur P, Basu S, Kaur G, Kaur R. Transfusion protocol in
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● Marieb EN, Hoehn K. Anatomy & Physiology. Hoboken, NJ:
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Boron WF, Boulpaep EL. Medical Physiology.; 2017.

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