What is an ECG?

ECG = Electrocardiogram

Tracing of heart heart’s electrical activity

Record of the electrical activity of the heart on

graph paper
 Uses of ECG

 Heart rate
 Cardiac rhythm
 Cardiac axis
 Myocardial ischemia / infarction
 Enlargement of cardiac chambers
 Drug toxicity
 Electrolyte imbalance
 THE CARDIAC ACTION POTENTIAL

1 Clinical books divide the

2 0 mV AP into a number of phases
0 - rapid depolarisation
50 1 - early repolarisation
mV 0 3 2 - plateau phase
3 - late repolarisation
4 - diastolic phase
100 ms 4

Tension
The AP has a duration similar to Intra-
contraction duration. The muscle is cellular
electrically refractory throughout the
contractile phase therefore making it
Ca2+
difficult to tetanise cardiac muscle.
 THE CONDUCTION SYSTEM OF THE HEART

sino-atrial node atrio-ventricular node • The AP originates at

the s-a node.
• AP propagates across
left the atrial walls
atrium bundle • The AP is delayed at
of His
the a-v node
• The AP propagates
rapidly down the
Purkinje Purkinje fibre
right fibres bundles
ventricle • The ventricular
myocardium is
depolarised
homogeneously
Propagating Activation Wavefront
 Propagating Activation Wavefront
Depol. toward positive electrode Repol. toward positive electrode
Positive Signal Negative Signal

Depol. away from positive electrode Repol. Away from positive electrode
Negative Signal Positive Signal
 Recording depolarization and
repolarization waves

Zero voltage - Isoelectric point

Resting stage - Polarized
 Flow of current in the chest around
partially depolarized ventricles.

Figure 11-5.
Copyright 2000, WB Saunders Company, All Rights Reserved
 Electrocardiogram (ECG/EKG)

• Is a recording of electrical activity of heart conducted thru ions in

body to surface

Fig 13.22a

13-60
 Electrical Activity of the Heart
• Contraction of heart depends on electrical
stimulation of myocardium
• Impulse is initiated on right atrium and
spreads throughout the heart
• May be recorded on an ECG
 Electrocardiogram
• Records electrical activity of the heart
• P wave
– Atrial depolarization
• QRS complex
– Ventricular depolarization
• T wave
– Ventricular repolarization
Fig. 13.22b
 Electrocardiogram (ECG):
Electrical Activity of the Heart

Figure 14-21: The electrocardiogram

 ECG
• 3 distinct waves are
produced during
cardiac cycle
• P wave caused by
atrial depolarization
• QRS complex caused
by ventricular
depolarization
• T wave results from
ventricular
repolarization

Fig 13.24
13-63
Elements of the ECG:
• P wave: Depolarization of both atria;
• Relationship between P and QRS helps distinguish various cardiac
arrhythmias
• Shape and duration of P may indicate atrial enlargement
• PR interval: from onset of P wave to onset of QRS
• Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes)
• Represents atria to ventricular conduction time (through His bundle)
• Prolonged PR interval may indicate a 1st degree heart block
• QRS complex: Ventricular depolarization
• Larger than P wave because of greater muscle mass of ventricles
• Normal duration = 0.08-0.12 seconds
• Its duration, amplitude, and morphology are useful in diagnosing cardiac
arrhythmias, ventricular hypertrophy, MI, electrolyte derangement, etc.
• Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are
abnormal and may represent MI
ST segment:
• Connects the QRS complex and T wave
• Duration of 0.08-0.12 sec (80-120 msec

T wave:
• Represents repolarization or recovery of ventricles
• Interval from beginning of QRS to apex of T is referred to as the absolute
refractory period

QT Interval
• Measured from beginning of QRS to the end of the T wave
• Normal QT is usually about 0.40 sec
• QT interval varies based on heart rate
 THE ELECTROCARDIOGRAM

PR interval - 0.12 - 0.20 s

R determined by delay of the AP at
the a-v node.
QRS complex time - 0.08 s
1 the time for AP propagation
mV T along the conduction system
P
ST segment.
Isoelectric region corresponding
Q to the ventricular AP plateau
S
QT interval.
Period of ventricular AP.
PR QRS ST
Interval is heart rate dependent.
QT QTc = QT/√RR
400 ms relatively independent of heart
rate.
 EKG Leads
Leads are electrodes which measure the
difference in electrical potential between either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point with

zero electrical potential, located in the center of the heart
(unipolar leads)
 EKG Leads
The standard EKG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads

The axis of a particular lead represents the viewpoint from which

it looks at the heart.
Standard Limb Leads
ECG Limb Leads
ECG Augmented Limb Leads
Summary of Limb Leads
The Precordial (Chest) Leads
 Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III -

(standard limb leads)

Unipolar aVR, aVL, aVF V1-V6

(augmented limb leads)
 Electrode placement in 12 lead ECG
4 are limb electrodes
Right arm -
I
+
-
Left arm -

Left leg
Right leg
II III
Ride Your Green Bike

The right leg electrode is a

+ +
neutral or dummy electrode.
 Electrode placement
6 are chest electrodes Called V1- 6
V1 4th intercostal space just right to the sternal edge
V2 4th intercostal space just left to the sternal edge
V4 over the apex (5th intercostal space on the mid-
clavicular line)
V3 halfway between V2 and V4
V5 at the same level as V4 but on the
anterior axillary line
V6 at the same level as V4 and V5 but
on the mid mid-axillary line
Arrangement of Leads on the EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
 Determining the Heart Rate
• Rule of 300

• 10 Second Rule
 Rule of 300
Take the number of “big boxes” between
neighboring QRS complexes, and divide this into
300. The result will be approximately equal to
the rate

Although fast, this method only works for

regular rhythms.
 Diagnostic use of the ECG
• ECG abnormalities may indicate coronary
heart disease
• ST-segment depression may indicate
myocardial ischemia