ECG method of investigation in

diagnosis of heart pathology.

Different kinds of ECG –
investigation and their clinical
significance. ECG sings of
authomaticiti lesions of the heart
 ACTUALITY
•The ECG can provide
evidence to support a
diagnosis, and in somecases
it is crucial for patient
management. It is, however,
important to see the ECG as a
tool, and not as an end in
itself. The ECG is essential for
the diagnosis, and therefore
management, of abnormal
cardiac rhythms.
• It helps with the diagnosis of the cause of chest pain, and
the proper use of thrombolysis in treating myocardial
infarction depends
upon it. It can help with the diagnosis of the cause of
breathlessness.
ECG – methods of registration of process depolarization and
repolarizaton of myocardium

Electrodes placed Standart bipolar leads by

red – right arm
yellow - left arm
green - left leg
black - right leg
V.Entchoven(1908)
I - right arm and left arm
IІ - right arm and left leg
III - left arm and left leg
Augmented leads
(Goldberger, 1942)

aVR (to II) – from right arm

aVL (to I) - from left arm
aVF (to III) – from left leg

Chest leads by Vilson

а - augmented V1 - in IV int.cost.sp to right from sternum
V - voltage V2 - in IV int.cost.sp to right from sternum
R - right V3 - between V2 i V4
L - left V4 - in V int.cost.sp on l. medioclavicularis
F - foot V5 - in V int.cost.sp on l. axillaris anterior
V6 - in V int.cost.sp. on l. axillaris media
 STANDART
BIPOLAR
LEADS
I
RA LA
1-standart lead

2-standart lead
III
II 3-standart lead
ECG

RL LL
CHEST LEADS
Left chest leads used for more topic
diagnostic of myocardial changes in basal of LV
ECG Waves and Intervals
 ECG Waves and Intervals
What do they mean?
P wave: the sequentialactivation (depolarization) of the right
and left atria
QRS complex: right and left ventricular depolarization
(normally the ventricles areactivated simultaneously)
ST-T wave: ventricular repolarization
U wave: origin for this wave is not clear - but probably
represents "afterdepolarizations" in the ventricles
PR interval: time interval from onset of atrial depolarization
(P wave) to onset of ventricular depolarization (QRS complex).
QRS duration: duration of ventricular muscle depolarization
QT interval: duration of ventricular depolarization and
repolarization
RR interval: duration of ventricular cardiac cycle (an indicator
of ventricular rate)
PP interval: duration of atrial cycle (an indicator of atrial rate)
 Maine components of ECG
It is important to remember that the P wave represents the
P Wave sequential activation of the right and left atria, and it is common
to see notched or biphasic P waves of right and left atrial
activation.P duration < 0.12 sec P amplitude < 2.5 mm. Frontal
plane P wave axis: 0o to +75o

QRS QRS duration < 0.10 sec.

Complex Frontal plane leads:
The normal QRS axis range (+90 o to -30 o ); this implies that the
QRS be mostly positive (upright) in leads II and I.
Normal q-waves reflect normal septal activation (beginning on the
LV septum); they are narrow (<0.04s duration) and small (<25%
the amplitude of the R wave). They are often seen in leads I and
aVL when the QRS axis is to the left of +60o, and in leads II, III,
aVF when the QRS axis is to the right of +60o. Septal q waves
should not be confused with the pathologic Q waves of
myocardial infarction. Small r-waves begin in V1 or V2 and
progress in size to V5. The R-V6 is usually smaller than R-V5. In
reverse, the s-waves begin in V6 or V5 and progress in size to V2.
S-V1 is usually smaller than S-V2.
Small "septal" q-waves may be seen in leads V5 and V6.
 Maine components of ECG
measured from beginning of P to beginning of QRS in the
PR Interval
frontal plane Normal: 0.12 - 0.20s

In a sense, the term "ST segment" is a misnomer, because a

ST Segment discrete ST segment distinct from the T wave is usually
and T wave absent. More often the ST-T wave is a smooth, continuous
waveform beginning with the J-point (end of QRS), slowly
rising to the peak of the T and followed by a rapid descent to
the isoelectric baseline or the onset of the U wave. This gives
rise to an asymmetrical T wave. In some normal individuals,
particularly women, the T wave is symmetrical and a
distinct, horizontal ST segment is present. The normal T
wave is usually in the same direction as the QRS except in
the right precordial leads. In the normal ECG the T wave is
always upright in leads I, II, V3-6, and always inverted in lead
aVR.

amplitude is usually < 1/3 T wave amplitude in same lead

U Wave: direction is the same as T wave direction in that lead U waves
are more prominent at slow heart rates and usually best seen
in the right precordial leads.
 ANALISIS ECG
Localization of pathological process:
Anterior wall of the heart - I, II, aVR, avL, V1 - V4
lower (posterior) wall - III, III on inspiration, aVF
Intraventricle septa - V3
Apex of the heart - V4
anterior-lateral wall of left ventricle - V5
lateral wall of left ventricle - V6

Rhythm of the heart

- regular (same distance Р- Р or R- R)
- irregular
- SA (Р positive before complex QRS in ІІ
і І eads. In all heart cycles in same lead
wave Р equal
- non SA
Heart rate
- one small square 1мм or 0,02 sec
- one big square 5мм or 0,1sec
- 60 (sec ) : R-R (sec)

•
 AXIS OF
THE HEART
Leads VR and II look at the heart
from opposite directions.
Seen from the front, the
depolarization wave normally
spreads through the ventricles
from 11 o’clock to 5 o’clock,
so the deflections in lead VR are
normally mainly downward
(negative) and in lead II mainly
upward (positive)
The average direction of sprea
of the depolarization wave
through the ventricles as seen
from the front is called the
‘cardiac axis’. The direction of
the axis can be derived most
easily from the QRS complex in
leads I, II and III. Wave R will b
greater in lead II than in I or III
(Fig. 1.14).
 AXIS OF THE HEART
LEFT RIGHT
 HYPERTROPHI OF THE LEFT VENTRICLE

Deviation of electrical axis to the

left 1. Deviation of electrical axis to the
RI > RII > RIII left
2. In І lead R, in ІІІ – deep S
3. Amplitude RІ+SІІІ more then 25
мм
4. Segment ST in І push down.
Т – small, by phases or negative
in І
5. In aVL R (11-13 мм and more),
in aVF – deep S
6. In V5-V6 – R, depression of ST
under isolinea, Т – small, by
phases or negative
7. Deep S in V1 , V2
8. Deviation of electrical axis of the
heart (angle ) to the left from 0
to +300 and more
 HYPERTROPHI OF THE RIGHT VENTRICLE

Deviation of electrical axis to the right

RI < RII < RIII 1. Deviation of electrical axis to
the right
2. In III lead R, in I – deep S.
Amplitude R in V1 іV2 more then
7 мм
3. Segment ST in III push down. T
– small, by phases or negative
4. In V5-V6 – deeper S
5. Deviation of electrical axis of
the heart (angle ) to the left
from +900 to +1200
 Pathological changers of waves and intervals
Р-mitrale expanded in І and ІІ
P P-pulmonale peaked in І and ІІ
Р- negative

PQ more then 0,2 sec

QRS Expanded more then 0,1 sec
decreased
Q Deeper more then 1/3 R, more then 0,03sec
Increased of amplitude
R Decreased of amplitude
Absent of R
S changers of am[litude, split

S-T displacement  more 1 мм or  more 0,5 мм from isolinea

T
incresased, decreased, expanded, by phases, negative
 S tachycardia
 Pacemaker - SA node Р І, II, aVF, V4–V6
 Rhythm correct
 Heart rate – 90-100-130, no more 160 in min.
 Waves of ЕCG normal, R-R decreased

S bradycardia
 Pacemaker - SA node Р І, II, aVF, V4–V6
 Rhythm correct
 Heart rate– less then 60 in min
 Waves of ЕCG normal, R-R > 1sec., Т-Р – increased

S arrhythmia
 Pacemaker - SA node Р І, II, aVF, V4–V6
 Rhythm ancorrect
 Heart rate– periods of increasing or decreasing
 Waves of ЕCG normal, R-R different
 AV rhythm
Pacemaker - А-V- node
HR – 30- 50 in min.
QRST – N
Р – negative
Supranodal impulse P before R
Mezonodal impuls P together with R
Infranodal impuls P after R

Idioventricullar rhythm
Pacemeker - bundle of His
HR –30-35 in min
Impulse from His bundle - QRST – normal
Impulse from branch of His bundle – QRST - increased