Basics of Electrocardiography

What is an ECG?
An ECG is the recording (gram) of the electrical activity(electro) generated by the cells of the
heart(cardio) that reaches the body surface.

Recording ECG

Useful in diagnosis of…

 Cardiac Arrhythmias

 Myocardial ischemia and infarction

 Pericarditis

 Chamber hypertrophy

 Electrolyte disturbances

 Drug effects and toxicity

Recording an ECG

 ECG graphs:
 1 mm squares
 5 mm squares
 Paper Speed:
 25 mm/sec standard
 Voltage Calibration:
 10 mm/mV standard

ECG Paper: Dimensions

ECG Leads
The standard ECG 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.

Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III (standard limb leads) -

Unipolar aVR, aVL, aVF (augmented limb leads) V -V

1 6
Anatomic Groups(Summary)
 Interpretation of an ECG
Steps involved

 Heart Rate

 Rhythm

 Axis

 Wave morphology

 Intervals and segments analysis

 Chamber enlargement

 Specific changes

Wave forms
Cardiac Conduction: Cycle Initiation
 Cardiac Conduction: P Wave

Cardiac

Conduction: AV Node

Cardiac Conduction: Bundle Branches

Cardiac Conduction: Purkinje Fibers
Cardiac Conduction: QRS Complex

Cardiac Conduction: Plateau Phase

Cardiac Conduction: T-Wave

 Label the ECG
P – Wave: Atrial Depolarization.

Can be positive, biphasic, negative.

QRS Complex: Ventricular Depolarization.

Q – Wave: 1st negative deflection wave before R-Wave.

R – Wave: The positive deflection wave.

S – Wave: 1st negative deflection wave after R – wave.

T – Wave: Ventricular Repolarization.

Can be positive, biphasic, negative.

Calculating Heart Rate

Measure Cycle Length (CL).
(# small boxes from R – R) (40ms) = CL .

Calculate HR

60,000/CL = “x” BPM

(20)(40ms) = 800ms
60,000/800 = 75 bpm

(25)(40ms) = 1000ms
60,000/1000 = 60 bpm

(12)(40ms) = 480ms
60,000/480 = 125 bpm

The Rule of 300

# of big boxes Rate

1 300

2 150

3 100

4 75

5 60

6 50

The QRS Axis

The QRS axis represents the net overall direction of the heart’s electrical activity.

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e. hemiblocks)
 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)

The QRS Axis

Determining the Axis

 The Quadrant Approach

 The Equiphasic Approach

Determining the Axis

Predominantly Positive Predominantly Negative Equiphasic

The Quadrant Approach

1. Examine the QRS complex in leads I and aVF to determine if they are predominantly positive or
predominantly negative. The combination should place the axis into one of the 4 quadrants below.

Example 1
 Example 2

Positive in I, negative in aVF  Predominantly positive in II 

Normal Axis (non-pathologic LAD)

Example 1
Equiphasic in aVF  Predominantly positive in I  QRS axis ≈ 0°

Example 2

Equiphasic in II  Predominantly negative in aVL  QRS axis ≈ +150°

Common causes of LAD

 May be normal in the elderly and very obese

 Due to high diaphragm during pregnancy, ascites, or ABD tumors

 Inferior wall MI

 Left Anterior Hemiblock

 Left Bundle Branch Block

 WPW Syndrome

 Congenital Lesions
 RV Pacer or RV ectopic rhythms

 Emphysema

Common causes of RAD

 Normal variant

 Right Ventricular Hypertrophy

 Anterior MI

 Right Bundle Branch Block

 Left Posterior Hemiblock

 Left Ventricular ectopic rhythms or pacing

 WPW Syndrome

The Normal ECG

Normal Sinus Rhythm

 Originates in the sinus node

 Rate between 60 and 100 beats per min

 P wave axis of +45 to +65 degrees, ie. Tallest p waves in Lead II

 Monomorphic P waves

 Normal PR interval of 120 to 200 msec

 Normal relationship between P and QRS

  Some sinus arrhythmia is normal

Sinus Arrhythmia

ECG Characteristics: Presence of sinus P waves

Variation of the PP interval which cannot be attributed to either
SA nodal block or PACs

When the variations in PP interval occur in phase with respiration, this is considered to be a normal variant.
When they are unrelated to respiration, they may be caused by the same etiologies leading to sinus
bradycardia.
 Normal P wave

PR

interval
 AV node conduction
 From the beginning of P wave to the beginning of q wave
 120-200 ms

Normal QRS complex:

 Completely negative in lead aVR , maximum positivity in lead II
 rS in right oriented leads and qR in left oriented leads (septal vector)
 Transition zone commonly in V3-V4
 RV5 > RV6 normally
 Normal duration 50-110 msec, not more than 120 msec
  Physiological q wave not > 0.03 sec

 ECG showing qR pattern in lead III ,disappears on deep inspiration  q wave not significant
 Mech:shift in the QRS axis

QRS-T angle
 The normal t wave axis is similar to the QRS axis
 Normally the QRS-T angle does not exceed 60 deg

Amplitude of QRS
Depends on the following factors:
 1.electrical force generated by the ventricular myocardium
 2.distance of the sensing electrode from the ventricles
 3.Body build;a thin individual has larger complexes when compared to obese individuals
 4.direction of the frontal QRS axis

Normal T wave
 Same direction as the
preceding QRS complex
 Blunt apex with
asymmetric limbs
 Height < 5mm in limb
leads and <10 mm in precordial
leads
 Smooth contours
 May be tall in athletes
ST segment

 Merges smoothly with the proximal limb of the T wave

 No true horizontality

Normal u wave
 Best seen in midprecordial leads
 Height < 10% of preceding T wave
 Isoelectric in lead aVL (useful to measure QTc)
 Rarely exceeds 1 mm in amplitude
 May be tall in athletes (2mm)
 QT interval
 Normally corrected for heart rate
 Bazett’s formula
 Normal 350 to 430 msec
 With a normal heart rate (60 to 100), the QT interval should not exceed half of the R-R
interval roughly
Measurement of QT interval

 The beginning of the QRS complex is best determined in a lead with an initial q wave
 leads I,II, avL ,V5 or V6
 QT interval shortens with tachycardia and lengthens with bradycardia
Prolonged QTc

 During sleep
 Hypocalcemia
 Ac myocarditis
 AMI
 Drugs like quinidine,procainamide,tricyclic antidepressants
 Hypothermia
 HOCM
 Advanced AV block or high degree AV block
 Jervell-Lange –Neilson syndrome
 Romano-ward syndrome
Shortened QT

 Digitalis effect
 Hypercalcemia
 Hyperthermia
 Vagal stimulation

Normal Variants in the ECG

  Sinus arrhythmia

Persistent juvenile pattern

 Early repolarisation syndrome

 Non specific T
wave changes

Persistent juvenile pattern

Features of ERPS
 Vagotonia / athletes’ heart
 Prominent J point
 Concave upwards, minimally elevated ST segments
 Tall symmetrical T waves
 Prominent q waves in left leads
 Tall R waves in left oriented leads
 Prominent u waves
 Rapid precordial transition
 Sinus bradycardia
Early Recognition Prevents Streptokinase infusion !
Reporting an ECG
1. Patient Details

“ Whose ECG is it ?!”

2. Standardisation and lead placement

“Is it properly taken ?”

3. Analysis of Rate, Rhythm and Axis
4. Segment and wave form analysis

Does the ECG correlate with the clinical scenario ?”