Electrocardiogram (ECG)

Dr. Madiha Imran

 Electrocardiogram

► Learning outcomes
● Introduction to ECG
● Basic principles of ECG
● Normal ECG
● Leads of ECG
● Cardiac vector and its analysis
● Current of injury
● Cardiac arrhythmias
● Effects of ECF electrolytes on ECG
● Clinical uses of ECG
 Electrocardiogram

Graphic record of electrical activity of heart

 Electrocardiogram

► Abbreviated as ECG or EKG

● A simple, cost effective & non invasive test
► A ‘coded language’
● Gives a lot of information about heart
► Cardiac electrophysiology
● Subspecialty of cardiology that deals with
ECG
 Electrocardiogram

► Electrocardiogram
● Graphic record of summated electrical
activity of heart obtained by placing
electrodes on body surface
 Electrocardiogram

► Electrocardiograph (ECG machine)

● Instrument used to record ECG on a
graphic paper
● A simple galvanometer
● Integral part of every medical unit
 Electrocardiogram

► Einthoven
● Fist to develop ECG
Machine in 1903
● For the first time
recorded EKG &
showed its clinical
relevance
● Won Noble Prize in
1924 Willem Einthoven
1860 - 1927
 Electrocardiogram

Action potential
Basis of electrocardiogram
 Electrocardiogram

► Cell membranes at rest are polarized

● Negative from interior as compared to exterior

ICF
 Electrocardiogram
When cells get stimulated When cells are at rest
•Action potential develops •Resting membrane potential
•Cell membrane becomes •Cell membrane negative
positive from interior from interior

- - - - -
- ++ + + -
-+ + -
- + -
- + -
-+ +-
- + +-
- + + + + -
- - - -
- - -
 Electrocardiogram
Important
► Action potential
● Records voltage inside the cells (difference
between cell interior and exterior)
► ECG
● Records voltage outside the cells (difference
between two points on outer surface of cells)
 Recording of
intracellular potentials
action potential
(monophasic recording)

ECF
 Recording of
extracellular potentials
ECG (biphasic recoding)

- - - - -
- ++ + + -
-+ + -
- + -
- + -
-+ +-
- + +-
- + + + + -
- - - -
- - - ECF
 Recording of
extracellular potentials
ECG (biphasic action
potentials)

ECF
 Electrocardiogram

ECG represents sum of all the action potentials

(electrical activity) of heart

► ECG
● Comprises of waves of depolarization &
repolarization
● As the wave of depolarization progresses through

the heart it causes myocardium to contract

 ECG

Ventricular action
potential
Cardiac impulse
 Cardiac impulse

► In electrophysiological sense
● Heart consists of two chambers
♦ Atria
♦ Ventricles
● Both the chambers are separated by non-
conducting fibrous ring except at bundle of His
 Cardiac impulse

Important

AV bundle (bundle of His) is the only route through

which cardiac impulse can enter from atria into
ventricles

Except AV bundle, ventricles

►
are electrically separated
from atria by a band of
fibrous ring (cardiac impulse
can’t pass through fibrous band)
 Propagation of cardiac impulse
Bundle of His (AV bundle)
Interatrial tract
(Bachman’s bundle) AV fibrous ring

Internodal Bundle branches

pathways

Purkinje fibers
AV fibrous ring
Propagation of cardiac impulse

Endocardium to epicardium
spread in ventricular wall
Propagation of cardiac impulse

R
T
P

Q
S
 Total time to depolarize
complete heart

.13
Right Left

Lower
Principles of ECG
 Principles of ECG

1. ECG
● Recording of voltage difference on outer

surface of cells
● Recording of summated electrical activity

(depolarization or repolarization) of many

cells
 Principles of ECG

ICF

Cell membrane of SA nodal cells- the

‘miniature battery’
 Principles of ECG

- +
---------

ICF

Cell membrane of SA nodal cells- the

‘miniature battery’
 Principles of ECG

0
- +

- +
+++++++++++++++++++

Myocardium
 Principles of ECG

0
- +

- Dipole +
--------------+++++++++

Myocardium
 Principles of ECG

0
- +

- Moving dipole +
- +- +- +- +- +- +- +- +- +- ++
+ - -+ -+ -+ -+ -+ -+ -+ -
+

Myocardium
 Principles of ECG

0
- +

- Moving dipole +
- +- +- +- +- +- +- +- +- +- ++
+ - -+ -+ -+ -+ -+ -+ -+ -
+

Myocardium
 Principles of ECG

2. No recording of voltage difference

● When heart muscle is

♦ Fully repolarized
■ Complete outer surface positive (no dipole)
♦ Fully depolarized
■ Complete outer surface negative (no dipole)
 Principles of ECG

0 Electrocardiograph
(galvanometer)
- +

- +
++++++++++++++
-

Complete repolarization
(cells at rest)
 Principles of ECG

0
- +

- +
--------------------
-

Complete depolarization
 Principles of ECG

3. Voltage difference is recorded

● When heart muscle is

♦ Partly depolarized
■ Some areas negative and some positive on outer
surface (development of dipole)
♦ Partly repolarized
■ Some areas negative and some positive on outer
surface (development of dipole)
 Principles of ECG

0
- +

Dipole
- +
----------+++++++
-

Partial depolarization or repolarization

 Principles of ECG

4. Wave of depolarization
● When moving towards positive electrode
♦ An upward wave on ECG is recorded
● When moving away from positive electrode
♦ A downward wave on ECG is recorded
 Principles of ECG

0
- +

+
Cardiac
vector
- +
----------+++++++
-

Wave of depolarization moving Upward deflection on ECG

towards positive electrode is recorded
 Principles of ECG

0
- +

+
Cardiac
vector
- +
+++++++----------
-

Wave of depolarization moving downward deflection on

away from positive electrode ECG is recorded
 Principles of ECG

5. Wave of repolarization
● When moving towards positive electrode
♦ A downward wave on ECG is recorded
● When moving away from positive electrode
♦ An upward wave on ECG is recorded
 Principles of ECG

0
- +

Cardiac
vector
- +
+++++++----------
-

Wave of repolarization moving Downward deflection on

towards positive electrode ECG is recorded
 Principles of ECG

0
- +

+
Cardiac
vector
- +
----------+++++++
-

Wave of repolarization moving Upward deflection on ECG

away from positive electrode is recorded
 0 0
- + - +
+
+
-
-

- + - +
- - - - - - - -+ + + + + + ++++++--------
Wave of depolarization Wave of depolarization

0 0
- + - +
+
+
-
-

- + - +
- - - - - - - -+ + + + + + ++++++--------
Wave of repolarization Wave of repolarization
 Principles of ECG

► Positive electrode
● If present in area of positivity
♦ An upward deflection (positive wave) will be
recorded
● If present in area of negativity
♦ A downward deflection (negative wave) will
be recorded
A B C

51
Principles of ECG
Principles of ECG
 Principles of ECG

6. Wave of depolarization or repolarization

moving at right angle to the imaginary
line joining two electrodes
● An equiphasic (half upward & half downward)
wave on ECG is recorded (net zero voltage)
 Principles of ECG
0
- +
-----+++++
+

- +

Cardiac
vectors -

Wave of depolarization or repolarization Zero net voltage;

moving at right angle to an imaginary equiphasic deflection on
line joining two electrodes ECG is recorded
 Principles of ECG

7. The magnitude of voltage difference is

directly related to the mass of tissue
undergoing depolarization or
repolarization
● Morethe mass larger will be the resultant
ECG wave and vice versa (QRS (ventricle)
complex has more magnitude than p
wave(atria))
 Principles of ECG

0
- +

+
Cardiac vector

- +
----------+++++++
-

Larger mass
Smaller mass Larger wave
Smaller wave
 ECG lead

8. Speed of current flow determines

● How wide the wave should be (time
duration of the wave)
 Principles of ECG

0
- +
+

Cardiac vector
- +
----------+++++++ -
 Orientation of the mean direction of current flow (mean
cardiac vector) relative to the recording electrodes determines
the polarity and amplitude of the recording wave

+++ +++
+++ +++
+++ +++
----
----
----
----
----
----
- - - - -

+ + + + +

Negative hemifield -
- -- -
-- - - -
- -- - - ++
-
-- - - - - +
- ++ ++ +
- +
++ ++ +
++ +
+ Positive hemifield
 Electrocardiograph - ECG machine

► A Galvanometer having an electromagnet

and amplifier
● Detects voltage difference
● Amplifier enhances the cardiac signal
● Electromagnet has two poles
♦ Positive & Negative
♦ Leads connect the poles of ECG machine with
electrodes
 Electrocardiograph - ECG machine

► Voltage keeps changing during spread of

cardiac impulse (moving dipole)
● Stylus (needle) of ECG machine moves up
and down with changing voltage
● Recording of voltage differences as a
function of time (in real time) is ECG
♦ Waves are recorded on ECG paper which moves
beneath the stylus at 25 mm per second speed
ECG leads
 ECG lead

► Pair of two electrodes connected to

electrocardiograph with wires constitute a
lead 0
- +

- +
--------++++++

A lead measures voltage difference between its two electrodes

ECG lead
ECG lead
ECG lead
ECG lead
 ECG lead
► Types of leads
● Bipolar leads
♦ Record voltage difference between a positive
and a negative electrode
♦ First leads to be recorded by Einthoven
● Unipolar leads
♦ ‘unipolar’ - a misnomer
■ true voltage at the site of positive electrode at each
instant
■ Voltage difference is recorded using two electrodes
 ECG lead

► Types of leads
● Unipolar leads
♦ Negative electrode
■ Is kept at zero voltage
■ Called indifferent electrode or central terminal
♦ Positive electrode
■ Records true voltage under positive electrode
■ Called exploring electrode
♦ Conventionally designated by letter ‘V’ (from voltage)
 ECG lead

In 12 lead ECG, all leads are unipolar except the

3 standard leads (I, II & III) used by Einthoven
 ECG lead

► Total leads used to record ECG

● 12

12 lead ECG

► Total electrodes used

● 10
♦ 9 electrodes are used for recording 12 leads
♦ 1 electrode is used for grounding
 12 lead ECG

Maximum leads are recorded by using minimum

number of electrodes judiciously

► 12 leads cover the heart from

anterior, inferior & lateral directions
 12 lead ECG

► In simple terms
● ECG records the results of 12 voltmeters
placed at different locations on the body in
real time
 12 lead ECG

► Limb leads (frontal plane leads)

● Bipolar leads (standard leads)
♦ I, II, III
● Unipolar leads
♦ aVR, aVL, aVF
► Chest leads (horizontal plane leads)
● Unipolar leads
♦ V1, V2, V3, V4, V5, V6
 Limb leads

► Limb leads
● Electrodes (positive & negative) are placed on
♦ left arm
♦ right arm
♦ left foot
● Record electrical activity in
frontal (coronal) plane
● Ground electrode (neutral)

♦ Right foot
 Limb leads

► Electrodes placed beyond 15 cm from

heart are considered equidistant in
electrical sense
● Record same electrical activity

Placing electrodes on wrists, arms or shoulders

yields same results
Electrode placement for exercise tolerance test (ETT)

Right arm Left arm

Right foot Left foot

 Bipolar (standard) limb leads
► Lead I
● Positive electrode on left arm
● Negative electrode on right arm
► Lead II
● Positive electrode on left foot
● Negative electrode on right arm
► Lead III
● Positive electrode on left foot
● Negative electrode on left arm
Right Lead I Left
Right Lead II Left
Right Lead III Left

-
+
Right Left

++
 ECG lead

► Axis of lead
● Axis of bipolar leads
♦ An imaginary straight line connecting the
positive and negative electrodes
● Axis of unipolar leads
♦ An imaginary straight line connecting the
exploring electrode with starting point (initial
negative end) of electrical activity of heart
 Bipolar limb leads

► Axes of bipolar limb leads

● Lie in frontal (coronal) plane
● Detect deviation of mean QRS vector in frontal
plane
 ECG lead

► Axis of lead (contd)

● By convention axis of a lead directs toward
the positive electrode
● Direction of axis is measured in degrees
 - 90°
-120° - 60°

- 150°
- 30°

- 180°
0°
+ 180°

150° 30°

120° 60°
90°
 270°
240° 300°

210° 330°

360°
180° 0°

150° 30°

120° 60°
90°
 ECG lead

► Axis of the leads remain fixed whereas

direction of mean current flow (mean
cardiac vector) keeps changing
● Relation between lead axis and direction
of current flow determines
♦ How large the wave should be (voltage)
♦ Whether the wave is up or down the base line
 ECG lead

Orientation of mean cardiac vector relative to

lead axis determines polarity and voltage of
resultant ECG wave in that particular lead
 Normal P wave vectors
Right Left
-
P wave

P wave
vector

+
98
 Normal P wave vectors
Right Left
+
P wave

P wave
vector

-
99
Recording in bipolar limb lead II
Right Left
-

R (base to apex
Apex to base vector)

Q S (apex to
Septal (septal base vector)
vector)

Base to apex
Normal QRS wave vectors
Three components (septal depolarization
Depolarization of entire ventricular mass
Depolarization of base
+ 101
Right Left
+

Apex to base
R (septal
vector) R (apex to
base vector)

Septal

S (base to apex
vector)

Base to apex
Normal QRS wave vectors
Three components (septal depolarization
Depolarization of entire ventricular mass
Depolarization of base
- 102
 Bipolar (standard) limb leads

► Einthoven’s triangle
● An equilateral Triangle formed by joining
the Axis of three Bipolar limb leads
♦ Electrodes placed on limb extremities are
electrically equidistant from heart
♦ Heart is considered to lie in the center of
Einthoven’s triangle
 Bipolar (standard) limb leads
► Einthoven’s law
● Algebraic sum of electrical potentials
of Bipolar limb leads I and III equals
that of lead II
I + III = II
► Kirchhoff's voltage law

(KVL)/Kirchhoff's loop rule

● The direct sum of the electrical potential
differences (voltage) around any closed
I +II+ III =0
circuit is zero
Einthoven’s triangle
 Bipolar (standard) limb leads

By pushing the axes of bipolar limb leads to

center of Einthoven's triangle, 3 intersecting lines
of reference are produced (triaxial system)
 Bipolar (standard) limb leads

Einthoven’s triangle

- I +
- -
II III I (0)

+ + III (120) II (60)

Axes of bipolar limb leads
(triaxial system)

- -
60 I
- +

+ + II
III
 Unipolar limb leads
► Frank Norman Wilson's (1932) &
Goldberger (1942)-Central terminal
► Also called ‘Augmented limb leads’

● Positive (exploring) electrode is placed on one

of the three limbs
● Other two limbs jointly act as negative
(indifferent) electrode (central terminal)
♦ Voltage of negative electrode is almost kept at
zero
 Unipolar limb leads

► Measure actual voltage under positive

electrode at a single point

Augmentation enhances the voltage

(amplitude of waves) by about 50%
 Unipolar limb leads

► Lead aVF
● Positive electrode on left foot
► Lead aVL
● Positive electrode on left arm
► Lead aVR
● Positive electrode on right arm
Right Lead aVF Left
Right Lead aVL Left
Right Lead aVR Left
 Unipolar limb leads

► Axes of unipolar limb leads

● An imaginary line connecting the exploring
electrode with the initial negative end of
electrical activity of ventricles
● Lie in frontal (coronal) plane
● Detect deviation of mean QRS vector in frontal plane
Axes of augmented limb leads
 Unipolar limb leads

Axes of unipolar limb leads form 3 intersecting

lines of reference (triaxial reference system)

► Unipolar limb leads view the heart from

angles different than bipolar limb leads
Axes of augmented limb leads

-
aVR aVL
+
+
60

- -
+
aVF
Axes of bipolar limb leads

- -
60 I
- +

+ + II
III
Bipolar limb leads Augmented limb leads
 Unipolar limb leads

► Fills the 60 angles (gaps) between axes

‘views’ of bipolar limb leads
● 60 angles (gaps) are reduced to 30
♦ Better view of electrical activity of heart
● Each lead axis is separated from its two
neighboring axes by 30
 Hexagonal (hexaxial) reference system

By superimposing the two triaxial reference

systems, a hexagonal reference system is formed
Axes of bipolar limb leads Axes of augmented limb leads

Hexagonal reference system

-150 (aVR) -30 (aVL)

0 (I)

120 (III)
60 (II)
90 (aVF)
 Axes of six limb leads
(hexagonal reference system)

- - -
aVR aVL
+ +
I
- +
- -
+ +II
III +
aVF
Hexagonal reference system

-
- -
-150° aVR aVL -30°
+ +
I
- 0°
+
- III II -
aVF
+ + +
+120° +60°
+90°

128
Hexagonal reference system

-150° aVR aVL -30°

+ +
I
0°
+

III II
aVF
+ + +
+120° +60°
+90°

129
 Hexagonal reference system

Each lead acts like a camera and takes

‘photograph’ of electrical activity from its
positive electrode
Hexagonal reference system
Hexagonal reference system

Lateral leads

Inferior leads
134
 Hexagonal reference system

Used to determine mean electrical axis of

ventricles (mean QRS vector) in frontal plane
 Chest (precordial) leads

► Unipolar leads
► Record electrical activity in horizontal

(transverse) plane
► Positive (exploring) electrode is placed on

chest
► All the three limbs jointly act as negative

(indifferent) electrode or central terminal

● Voltage of negative electrode is kept at zero
 Chest (precordial) leads
► V1
● 4th intercostal space just right of sternum
► V2
● 4th intercostal space just left of sternum
► V4
● 5th intercostal space mid clavicular line
► V3
● Between V2 and V4
► V5
● 5th intercostal space anterior axillary line
► V6
● 5th intercostal space mid axillary line
Chest (precordial) leads
1 2 6
3 5
4
Chest (precordial) leads
 Chest (precordial) leads

► Axes of chest leads

● An imaginary line connecting the exploring
electrode with the initial negative end of
electrical activity of ventricles
● Lie in horizontal (transverse) plane
♦ Detect deviation (rotation) of mean QRS vector in
horizontal plane
Chest (precordial) leads

Axes of six chest leads

(Limb leads plane)

(Chest leads plane)

Chest (precordial) leads
 12 lead ECG
The 12-lead ECG is today

► Three limb leads I, II and III from

Einthoven;
► Three augmented unipolar limb leads aVR,

aVL, and aVF from Goldberger’s

modification of Wilson’s central terminal;
► Six precordial leads V1–V6 arising out of

the Wilson terminal.

 Frontal & horizontal plane leads

► Cardiac vector (wave of depolarization)

moves in three dimensions
● Up down, right left, anterior posterior
► ECG leads in more than one plane are
required to detect 3 D cardiac vector
 Frontal & horizontal plane leads

► In practice, leads in 2 planes are used

● Frontal (coronal) plane
● Horizontal (transverse) plane

Leads in two planes detect three

dimensional cardiac vector

► No need to place leads in 3rd (sagittal)

plane
 Frontal & horizontal plane leads

► Frontal plane leads

● Limb leads
♦ Record electrical activity in frontal plane
(superior, inferior & right, left)
► Horizontal plane leads
● Precordial leads
♦ Record electrical activity in horizontal plane
(anterior, posterior & right/left)
AV node (Electrical centre of heart)

151
ECG Leads
Normal electrocardiogram
U U
 Ventricular depolarization
(QRS complex)
Papillary muscle or Purkinje
Atrial fibers repolarization
depolarization
Ventricular
repolarization

U U

AV nodal delay Plateau phase

 ECG

Ventricular action
potential
 Normal electrocardiogram

Atrial repolarization wave (atrial T wave)

►
● Not recorded in a normal ECG
● Coincides in time with QRS complex

formation
♦ Merges within QRS complex
● Very small and upward wave (when recorded)
 Normal electrocardiogram

► Isoelectric line (segment)

● A flat line on ECG recording with out
any wave
► Interval
● A flat line on ECG recording having at
least one wave
 QRS
complex
RR
PR (PQ) R interval
interval

ST
segment
J point

PR
segment TP
QT Segment (interval)
interval
 1 small square (ss) = 1 mm (each side)

Voltage
1 mm (1 ss) = 0.1 mv
1 large square = 0.5 mv
Time

At ECG machine speed of 25 mm/sec

1 mm (1 ss) = 0.04 sec
1 large square = 0.2 sec

300 large squares (1500 small squares) = 1 minute

300x0.2=60 or 1500x0.04=60 161
 1 mm

1 mm

0.5 mv

Voltage (mv)

0.1 mv

Time (sec) 0.04 sec 0.2 sec

ECG machine speed of 25 mm/sec
 R

T
P P

Q
S
 QRS complex
0.06 = 0.1 sec

PR interval RR interval (cardiac cycle = 0.8 sec)

0.12 - 0.2 sec R 0.6 - 1.0 sec

QT interval
0.3 - 0.44 sec (varies with heart rate)
 Normal electrocardiogram
► P wave
● Voltage 0.1 to 0.3 mv (1 to 3 small squares)
● Duration 0.08 to 0.1 sec (2 to 2.5 small squares)
► QRS complex
● Voltage 0.5 to 4 mv (5 to 40 small squares)
● Duration 0.06 to 0.1 sec (1.5 to 2.5 small squares)
► T wave
● Voltage 0.2 to 0.3 mv (2 to 3 small squares)
● Duration 0.16 to 0.2 mv (4 to 5 small squares)
 Normal Electrocardiogram

► J point
● Point when both the ventricles are
completely depolarized
♦ The only time when ventricles have same
charge (negative) on outer surface
♦ No voltage difference is shown on ECG
■ Baseline at ‘zero’ voltage level (zero reference
level)
 R

T
P J U

Q S

168
 Normal electrocardiogram

► Calculation of heart rate

● 60/time in sec between 2 consecutive R waves
● 300/no of large squares between 2
consecutive R waves
● 1500/no of small squares between 2
consecutive R waves
● 6 second strip (30 large squares)
♦ R waves in 30 large squares (6 sec) × 10
300 large squares (1500 small squares) = 1 minute
300x0.2=60sec or 1500x0.04=60sec
Heart Rate
 Cardiac vector

► Any entity having direction and magnitude

can be represented by a Vector
 Cardiac vector

► Electrical currents generated in the heart

(waves of depolarization or repolarization) have
both
● Direction and
● Magnitude

So, can be represented by vectors

 Cardiac vector

Cardiac vector is a moving wave of depolarization

or repolarization
 Cardiac vector

► Represented by an arrow
● Arrow head points towards positive charges
● Length of arrow represents voltage
 Cardiac vector

► Instantaneous vector
► Instantaneous mean vector
 Cardiac vector

► Instantaneous vector
● Vector at any point in time
► Instantaneous mean vector
● Average of many instantaneous vectors at
any point in time
 Instantaneous vectors for ventricular depolarization

Right Left

178
 Instantaneous mean vector

► Net resultant vector at each instant after

summation or cancellation of individual
(instantaneous) vectors
► Recorded on ECG in wave form

● Atrial instantaneous mean vectors

● Ventricular instantaneous mean vectors
 Instantaneous mean vector

For five waves visible on ECG (P, Q, R, S, T) there

are five instantaneous mean vectors
 Atrial Instantaneous mean vector

► Atrial instantaneous mean vectors

● Atrial depolarization vector
● Atrial repolarization vector
Ventricular Instantaneous mean vector

► Ventricular instantaneous mean vectors

● Ventricular depolarization vectors
♦ Septal vector
♦ Base to apex vector
♦ Apex to base vector
● Ventricular repolarization vector
 Atrial Instantaneous mean vector

► Atrial instantaneous mean vectors

● Atrial depolarization vector (synthesis of P wave)
♦ Downwards, leftwards (40 to 60 degrees)
♦ Forms ‘P’ wave
● Atrial repolarization vector
♦ Upwards, rightwards
♦ Forms atrial ‘T’ wave (not seen on ECG)
 Instantaneous mean vectors for atrial depolarization

Right Left
-
P wave

P wave
vector

+
184
 Instantaneous mean vector

► Atrial repolarization vector

● Forms atrial T wave (Ta)
● Opposite to atrial depolarization vector
♦ Starts from SA node (as for depolarization vector)
♦ Polarity of atrial T wave is opposite to that of P
wave
 Normal P wave & Ta wave vectors
Right Left

Ta wave
vector P wave

P wave
vector Atrial T wave

186
 Instantaneous mean vector

► Ventricular instantaneous mean vectors

● Ventricular depolarization vectors (synthesis
of QRS complex)
1. Septal vector
■ Left to right & upward
■ Forms ‘Q’ wave in left oriented leads
2. Base to apex vector
■ Right to left & downward
■ Forms ‘R’ wave in left oriented leads
 Instantaneous mean vector

► Ventricular instantaneous mean vectors

● Ventricular depolarization vectors (synthesis
of QRS complex)
3. Apex to base vector
■ Left to right & upwards
■ Forms ‘S’ wave in left oriented leads
Right Left
-

R (base to apex
Apex to base vector)

Q S (apex to
Septal (septal base vector)
vector)

Base to apex

+ 189
Instantaneous mean vectors for ventricular depolarization

Right Left

190
Instantaneous mean vectors for ventricular depolarization

Right Left

191
 Instantaneous mean vector

► Ventricular instantaneous mean vectors

● Ventricular Repolarization vector (synthesis
of T wave)
♦ Base to apex vector
■ Forms ‘T’ wave
 Synthesis of T wave

► Subendocardial muscle
● Depolarizes first
● Longer action potential
♦ Less number of ‘transient outward’ K+
channels
■ Less outward K+ current
● Repolarizes last
 Synthesis of T wave

► Subepicardial muscle
● Depolarizes last
● Shorter action potential
♦ More number of ‘transient outward’ K+
channels
■ More outward K+ current
● Repolarizes first
 Cardiac vector

Subendocardial muscle depolarizes first but

repolarizes last
 Synthesis of T wave

Subepicardial muscle near apex is the first part

to repolarize so repolarization wave moves
upwards and rightwards

► T wave vector points downwards &

leftwards (arrow head points towards area of
positivity)
Repolarization wave moving upward & rightward

Right Left

197
Repolarization vectors moving downwards & leftward

Right Left

T wave instantaneous
mean vector
198
 Synthesis of T wave

► During repolarization
● Outer epicardium is the first part to become
positive
● T wave vector remains base to apex (like
QRS complex)
● T wave polarity is similar to QRS complex
 Normal T wave vector

Right Left

T wave vector

200
 Normal mean QRS & T wave vectors
Right Left
R wave

T wave

T wave vector

Mean QRS vector

201
 T wave

► Most sensitive wave of ECG

● Represents ventricular repolarization
♦ Changes in repolarization pattern change
shape of T wave

Myocardial ischemia, most important factor to change

repolarization pattern & therefore T wave shape
 Instantaneous mean vector

It is the instantaneous mean vector that is "seen"

by recording electrode at a given instant of time
 Instantaneous mean vector

Instantaneous Mean Vector is recorded on ECG

according to its relation with a particular lead axis

► All the 12 leads have different lead axes

● ECG wave pattern is not similar in different leads
 Mean QRS vector

► Average of all the instantaneous mean

vectors during ventricular depolarization
● Also called electrical axis of heart (ventricles)
● Leftwards and downwards
♦ Generally parallel with lead II axis
 Significance of Mean QRS vector

► Significance of mean QRS vector

● Determination of right & left axis deviation
♦ Conduction blocks
♦ Ventricular hypertrophy
♦ Myocardial infarction
♦ Ectopic foci
 Mean QRS vector

► Direction is determined by Hexagonal

reference system
● Normal direction
♦ About + 59° (60°) in frontal plane
● Deviation from normal range indicates
cardiac pathology
♦ Axis deviation
Right Left

Mean QRS vector

208
Right Left

59°

60°
II
Mean QRS vector
 Frontal plane mean
QRS vector
• Downwards
• leftwards

0 Horizontal plane mean

QRS vector
• Posteriorly
• leftwards
Leads at right angle to each other

270
240 300
-
- -
210 aVR aVL 330
+ +
I 360
180 - + 0
- III II - 30
150
aVF
+ + +
120 60
90

211
Leads at right angle to each other

► I and aVF
► II and aVL
► III and aVR
 Mean QRS vector

► Mean QRS vector (mean electrical

axis of heart)
● Normal directions (in frontal plane)
♦ -30 to +110
♦ Generally 0 to +90 (left lower quadrant)
 Mean electrical axis of heart

-90

Extreme Left axis

right axis deviation -30
deviation

z
180 0
Right axis Normal
deviation axis

60

+110 +90
 Mean electrical axis of heart

-90

Extreme Left axis

right axis deviation -30
deviation

z
180 0
Right axis
deviation
Normal
quadrant

60

+110 +90
 Mean QRS vector

► Mean QRS vector

● Left axis deviation
♦ From -30 to -90
● Right axis deviation
♦ From +110 to +180
● Extreme right axis deviation
♦ Between 180 and - 90
 Determination of Mean QRS Vector
(Mean Electrical Axis)

- + Lead 1 0⁰

Mean QRS vector

Lead 3 +
120⁰
 Vectorial analysis

► Conditions affecting Mean QRS Vector

● Ventricular hypertrophy
♦ Deviates towards hypertrophied ventricle
● Bundle branch block
♦ Deviates towards the block
● Myocardial infarction
♦ Deviates away from infarction
● Ventricular ectopic pace maker
♦ Depends upon location of the pace maker
 Current of Injury

► Diagnosis of ‘current of injury’ (acute

injury to myocardium or acute myocardial
infarction or heart attack)
● One of the main functions of ECG
 Current of Injury

Wave on ECG appears when vector is formed

from ‘zero’ and comes back to ‘zero’

► If vector is formed and does not come

back to ‘zero’
● Wave will not be formed but
● Base line will shift towards positive end
of vector
 Current of Injury

► Flow of current from damaged to normal

area of heart between heart beats is
called current of injury
► Damaged area (semi viable)
● Remains depolarized (negative outwards)
 Current of Injury

► Baseline shift
● Repolarization does not complete
♦ Persistence of repolarization wave (injury
current)
● T wave does not come to base line
♦ Baseline shifts upwards or downwards
Thank you