Conduction Pathways

• Sinoatrial Node
• Atrioventricular Node
• AV Bundle
• Bundle Branches
• Purkinje Fibers
 EKG: Sinus rhythm
• Implies origin is from the SA node
– Not from an ectopic atrial focus
• P wave for every QRS complex
• P wave upright in leads I, II, III
 Normal Sinus Rhythm

• Rate: 60 to 100 bpm

• Rhythm: Regular, sinus
• Intervals: normal
 Sinus Bradycardia

• Rate: <60 bpm

• Rhythm:regular, sinus
• Intervals: normal
 Sinus Tachycardia

• Rate: > 100 bpm

• Rhythm: regular, sinus
• Intervals: normal
 Sinus Arrhythmia
• Impulse is initiated by the SA node
– P waves all identical
• Consistent and normal PR intervals
• IRREGULAR R to R intervals
• Common in children and young adults
• Varies with inspiration
 Sinus Arrest
• SA node fails to initiate an impulse
• NO PQRST complex
• Causes:
– Hypoxia
– Ischemia/infarction
– Myocarditis
– Increased vagal tone
– Drugs (digitalis, salicylates)
Sinus Arrest
 First Degree AV Block
• Fixed, prolonged PR interval >200 ms
• Population
– Highly conditioned athletes
– History of MI, myocarditis
– Medication induced
• Ca channel blockers, Beta-blockers, digitalis
First Degree AV Block
 Second Degree AV Blocks

• Some P waves fail to conduct to ventricles and

generate a QRS complex

• Mobitz I (Wenckebach)
– Progressive prolongation of PRI resulting in a dropped
QRS
– Delay at the AV node (72%) or HIS -Purkinje system
(28%)

• Mobitz II
– Sudden unexpected blocked P waves
– No variation in PRI
– “randomly” dropped beats
Second Degree AV Blocks
 The AV Blocks
• Third Degree Block
– AV dissociation
– Escape beat
• AV nodal – rate normal
– Narrow complex
• Junctional – rate 40-60’s
– Narrow complex
• Ventricular – rate 30-40’s
– Wide complex, bizarre shape
 Third Degree AV Block
• Complete Heart Block
• Complete absence of AV conduction
• Block is at level of AV node, HIS bundle or
bundle branch-Purkinje system
• QRS duration depends on site of block
 Wide QRS = Bundle Branch Block
• Left (LBBB)
• Right (RBBB)
• Left Anterior Fascicular Block (LAFB)
• Left Posterior Fascicular Block (LPFB)
 PRE-MATURE CONTRACTIONS
OR EXTRA SYSTOLE
Extra systole means pre-mature excitation
and contraction of entire heart or some of
its portions.
Depending on their origin
1. Atrial extra systole.
2. AV junctional extra systole.
3. Ventricular extra systole.
Premature Atrial Contractions

– P wave is from ectopic focus

• Different morphology
– Normal QRS
– Occur early in the cycle (premature)
– have a compensatory pause
– Can occur in healthy individuals or secondary
to CHF, ischemia, COPD
 ATRIAL EXTRA SYSTOLE
• Results in deformation of P wave during
extra systole.
• From superior portion of atria P wave is
positive and deformed.
• From middle portion of atria P wave is
biphasic or flattened P wave.
• From inferior atrial extra systole excitation
propagates through the atria retrogradely
this leads to negative P wave.
PACs
 AV JUNCTIONAL EXTRA
SYSTOLE

• Excitation and AV junction transmits

impulses retrogradely so QRS- T wave
normal.
• Mising P wave, or P wave is superimpose
on to QRS-T complex.
A.V nodal premature contraction
 Ventricular Extra systole
• From intra ventricular
conducting system or
from ventricular
myocardium.
• QRS complex is
widened.
• QRS complex is 0.12
seconds or more.
 PAROXYSMAL TACHYCHARDIA
• Paroxysmal means that the heart rate
becomes rapid in paroxysms, with
paroxysm beginning suddenly and
lasting for a few seconds or minutes then
paroxysm ends suddenly
1. Atrial paroxysmal tachychardia.
2. AV paroxysmal tachychardia.
3. Ventricular paroxysmal tachychardia.
Ventricular fibrillation
To Demonstrate the direction in which the depolarization is
moving we use the vector which is an arrow
 Axis refer to the direction of depolarization which spreads
throughout the heart to stimulate the myocardium to contract
Axes of the three bipolar and three unipolar leads
Mean vector through the partially
depolarized ventricles
Vectorial analysis of the normal ECG
 Axis Basics
• The axis measures the direction of the overall
electrical activity of the heart

• Hypertrophy of either ventricle can displace

the axis:
– Left Ventricular Hypertrophy (LVH) can
result in Left Axis Deviation (LAD)
– Right ventricular Hypertrophy (RVH) can
result in Right Axis Deviation (RAD)
– Similarly Bundle Branch Blocks can
distort the axis
 Approach to EKG Axis
• The Limb Leads are used to determine the
axis

• Normal axis usually results in a + QRS

complex (majority of the complex is above
the baseline) in leads I, II, III & aVF

• A normal axis falls between 0° & +90°

• However, many authorities consider a normal

axis between –30° & +105°
 The QRS Axis
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to +90°.

-30° to -90° is referred to as a

left axis deviation (LAD)

+90° to +180° is referred to as

a right axis deviation (RAD)
 Lead I If lead I is positive, the
-90 green zone reveals the
_
+ area of electrical activity

I
0

aVF
– aVF If aVF is positive, the
-90 red zone reveals the area
of electrical activity

I
0

aVF
 -90

I
0

If we superimpose these
aVF onto one another we
+90 find the axis to be
between 0° & +90°
EKG with a Normal Axis.
 LAD
• May be caused by: HTN, aortic valvular
disease & cardiomyopathies

• Once you have determined that the axis

lies between 0° & –90°, it is clinically
useful to decided if it is between –30° &
–90°, as this is true LAD
 If lead I is positive then
Lead I
_ -90
the blue zone is the area
+
of electrical activity

I
0

aVF
+90
_
aVF If aVF is negative, the
-90
green zone is the area of
electrical activity

+
I
0

aVF
+90
 If we superimpose these
-90 onto one another we
find the axis to be
between 0° & –90°

I
0

aVF
+90
 True LAD

• So again, if lead I is positive and aVF is

negative, we suspect LAD

• To diagnose true LAD, we examine lead

II:
– If lead II is positive, axis = 0° to –30°
– If lead II is negative , axis = –30° to –90°
EKG with true LAD
 RAD
• Right axis deviation is usually
secondary to an enlarged right ventricle
or pulmonary disease

• Some of the ethiology include:

pulmonary HTN, COPD or acute PE
 If lead I is negative the
Lead I green zone encompasses
_ + -90
the area of electrical activity

I
180 0

aVF
+90
_ If aVF is positive, the
aVF
-90 red zone reveals the area
of electrical activity

+
I
180 0

aVF
+90
 -90

I
180 0

If we superimpose these aVF

onto one another, we
+90
find the axis to be
between 90° & 180°
 Extreme RAD

• If lead I is negative AND aVF is also

negative – extreme RAD
• Clue: If aVR is positive = extreme RAD
• This is seen with rare situations such as VT
or Pacemakers
• In general we should never have an axis
over here!
EKG with Right Axis Deviation
 EKG Axis Summary
• look at lead I and aVF:
– if both are positive = Normal axis
– If I is positive but aVF is negative = probable LAD
• If between 0° & –30° = upper limits of normal
• If between –30° & –90° = True LAD (check lead II
to determine)
– If I is negative = RAD (axis > 90°)…you can be more
specific and decide:
• If between +90 & +120 = upper limits of normal
• If between +120 to +180 = True RAD
– When both I & aVF are negative, axis is between -90
and +/-180 – this is Extreme RAD