Electrocardiography . Heart Sounds. Pressure pulse.

Electrocardiography
ELECTROCARDIGRAM - record of the electrical changes during the cardiac
cycle is known as electrocardiogram.

The spread of excitation (action potentials generated in the muscle cells of the heart)
through the myocardium occurs in much the same way as conduction in unmyelinated
nerve fibers. Local electrical circuits are established and small currents flow through
the extracellular fluid. The passage of these currents through the extracellular fluid
creates small potential differences which may be sensed by appropriately positioned
electrodes and recorded as an electrocardiogram or ECG.
The ECG provides a means of recording the electrical activity of the heart in situ.
The ECG is recorded by placing electrodes at different points on the body surface
and measuring voltage differences between these points. Any particular position of a
pair of electrodes on the body surface will detect a particular portion of the current
flow during depolarization and repolarization, so that a complete picture of the spread
of excitation requires information from a number of electrode placements, or leads.
There are two types of ECG leads, bipolar and unipolar.
Bipolar leads record the voltage between electrodes placed on the wrists and ankles
(with the right ankle acting as the earth).
Unipolar leads record the voltage between a single electrode placed on the body
surface and an electrode that is maintained at zero potential (earth).

ECG leads
The three standard bipolar limb leads are, by convention, known as limb leads I, II,
and III. These are illustrated in Fig. 15.6.
In lead I, the positive terminal of the amplifier is connected to the left arm and the
negative terminal to the right arm. With this placement of electrodes, the amplifier
records the component of excitation that is moving along an axis between the right
and left sides of the heart.
In lead II the right arm is the negative terminal and the left leg the positive, so that the
component of excitation moving from the right upper portion of the heart to the tip of
the ventricles is recorded.
In lead III, the left leg is the positive terminal and the left arm the negative. This lead
records the component of excitation spreading along an axis between the left atrium
and the tip of the ventricles.
Two types of unipolar leads are used in electrocardiography :
· The augmented limb leads
· The chest (precordial) leads.
 DESCRIBE AUGMENTED UNIPOLAR LEADS
There are three unipolar augmented leads - aVR, aVL, aVF. Any of the three
limb electrodes can be used to record cardiac potential in comparison to the common
terminal, e.g. voltage recorded in RA (right arm) can be determined by the equation.
RA - (RA+LA+LL) the resulting voltage is small because the potential
difference is reduced by the RA potential in common terminal, i.e. (RA+LA+LL).
Disconnecting the RA lead from the common terminal increases the potential
difference by 50% and results in augmented limb lead aVR.
aVR - is the potential difference between RA and (LA+LL).
aVL - is the potential difference between LA and (RA+LL).
aVF - is the potential difference between LL and (RA+LA).
In this type of recording two of the limbs are connected through electrical
resistances to the negative terminal of the electrocardiograph while the third limb is
connected to positive terminal.
DESCRIBE UNIPOLAR CHEST LEADS
When the ECG is recorded using the unipolar chest leads, a reference electrode
is produced by joining the three limb leads while an exploring electrode records from
specific points on the chest at the level of the heart (Fig. 15.7). There are six such
precordial leads called as “V” leads.
Lead V1 - in the fourth intercostal space, just to the right of the sternum;
Lead V2 - in the fourth intercostal space, just to the left of the sternum;
Lead V4 - in the midclavicular line in the fifth left intercostal space;
Lead V3 - halfway between V2 and V4;
Lead V5 - in the anterior axillary line at the same level as V4;
Lead V6 - in the midaxillary line at the same level as V4 and V5.

The characteristics of the normal ECG recorded

The normal ECG consist from waves and intervals and complex. Although each
cardiac cycle is initiated by depolarization of the sinoatrial node, this electrical event is
not seen in the ECG trace because the mass of tissue involved is small.
1. P wave - it is due to atrial depolarization. It is normally positive (upright) in the
standard limb leads and inverted in aVR lead.
2. P-R interval. It is measured from the onset of P wave to the onset of QRS complex.
Actually it is PQ interval but Q wave is frequently absent and therefore it is
called P-R interval. It is measure of the atrium-ventricular conduction time and
includes the delay through atriumventricular node. It’s duration normally varies
from 0.12 to 0.2 s depending upon heart rate.
3. The next electrical event of the cardiac cycle is reflected in the QRS complex of the
ECG trace. QRS complex. It is caused by ventricular depolarization. Its duration
is normally less than 0.08 second. It is a measure of intraventricular conduction
time.
4. QT interval. It is measured from begining of “Q” wave to the end of “T” wave.
Normally it is 0,35 second. Ventricular contraction usually lasts almost during
this interval.
5. S-T interval. During the interval between the S and the T waves the entire
ventricular myocardium is depolarized and the ventricles contract. Because all
the myocardial cells are at about the same potential, the S-T segment lies on the
isoelectric line. This corresponds to the long plateau phase of the cardiac action
potential.
6. The final major event of the ECG trace is the T wave. T-wave. It is caused by
ventricular repolarization and is normally in the same direction as the QRS
complex, since ventricular repolarization follows the path that is opposite to
depolarization.
7. R-R interval. It is the time interval during successive QRS complexes. If it is 1s.,
heart rate is 60 beats/min. Normally it is 0,83 s and therefore heart rate is
60/0,83 = 72 beats/min.

PRINCIPLES OF VECTORIAL ANALYSIS OF ELECTROCARDIOGRAMS

Use of vectors to Represent electrical potentials

The heart current flows in a particular direction at a given instant during the
cardiac cycle. A vector is an arrow that points in the direction of the electrical potential
generated by current flow, with the arrowhead in the positive direction. Also, by
convention, the length of the arrow is draw proportional to the voltage of the potential.

“Resultant” vector in the heart at any given instant

Figure 12-1 (Guyton & Hall) shows, by way of the shaded area and the negative
signs, depolarization of the ventricular septum and beginning parts of the lateral
endocardial walls of the two ventricles. Electrical current flows between these
depolarized areas inside the heart and nondepolarized areas on the outside of the heart,
as indicated by the long elliptical arrows. Some current also flows inside the heart
chambers directly from the depolarized areas toward the still polarized areas. Even
though a small amount of current flows upward inside the heart, a considerably greater
quantity flows downward on the outside of the ventricles toward the apex. Therefore,
the summated vector of the generated potential at this particular instant, called the
instantaneous mean vector (or mean electrical axis or the mean QRS vector), is
represented by the long black arrow drawn throgh the center of the ventricles in a
direction from the base of the heart toward the apex.

When a vector is exactly horizontal and directed toward the person’s left side,
the vector is said to extend in the direction of 0 degrees, as shown in Figure 12-2. From
this zero reference point, the scale of vectors rotates clockwise; when the vector
extends from above, downward, it has a direction of +90 degrees; when it extends from
the subject’s left tj his or her right ,it has a direction of +180 degrees: and when it
extends upward, it has a direction of -90 (or +270) degrees.
 In a normal heart, the average direction of the vector during spread of the
depolarization wave is about +59 degrees, which is shown by vector A drawn through
the center of Figure 12-2 (Guyton & Hall 1 Volume) in the +59-degree direction. This
means that during most of the depolarization wave,the apex of the heart remains
positive with respect to the base of the heart.
Vectorial Analysis of potentials in the three standard bipolar limb leads
In Figure 12-6 (Guyton&Hall) vector A depicts the instantaneous electrical
potential of a partially depolarized heart. To determine the potential recorded at this
instant in the electrcardiogram for each one of the three standard bipolar limb leads,
perpendicular lines (the dashed lines) are drown from the tip of vector A to the three
lines representing the axes of the three different standard leads as shown in the figure.
The projected vector B depicts the potential recorded at the instant in lead 1,projected
vector C depicts the potential in lead II, and projected vector D depicts the potential in
lead III. In each of these, the record in the electrocardiogram is positive - that is, above
the zero line - because the projected vectors point in the positive directions along the
axes of all the leads.

The cardiac cycle and the heart sounds

The heart sounds
Closure of the valves of the heart is associated with audible sounds. Normally the
heart sounds are heard with a stethoscope which are described as first and second heart
sounds. Occasionally third heart sound which is very weak is heard. But fourth heart is
not heard by stethoscope because it very low frequency. It can only be recorded in
phonocardiogram (Fig.13-13 from J. Joshi).
The heart sounds are caused by turbulence in the flow of blood.
Heart sounds are not directly heard over the valves themselves but they are better
heard over four auscultatory areas.
1. Mitral area - This area lies over the apex beat (normally in the fifth left intercostal
space three and half inches lateral to the midsternal line).
2. Tricuspid area - this lies at the lower end of sternum.
3. Aortic area - this area lies in the right second intercostal space near the lateral
border of the sternum.
4. Pulmonary area - this area lies in the left second intercostal space near the lateral
border of the sternum.
Both the heart sounds, first and second are heard in all four auscultatory areas, but at
mitral and tricuspid areas first heart sound is better heard because sound caused by A-
V valves are transmitted to the chest wall through the respective ventricles. Second
heart sound is better heard over the aortic and pulmonary areas because sounds caused
by closure of semilunar valves are transmitted to the aorta and pulmonary artery.

The first heart sound begins to be heard at the onset of ventricular systole and is
associated with the closure of the atrioventricular valves. This sound begins
immediately after the R wave of the ECG. It is like a word LUBB. It is better heard
over mitral and tricuspid areas. Slapping together of valve leaflets sets up vibrations
causing vibrations of the adjacent blood, walls of the heart and major vessels around
the heart. Contraction of ventricle causes valves to bulge against atria until chordae
tendineae abruptly stop the backbulging. The elastic tautness of the valves (tricuspid
and mitral valves) then cause backsurging blood to bounce forward again into each
respective ventricle. This sets blood, ventricular walls and valves into vibration. The
duration of the first sound is 0,14 s, and is low pitched.
Significance
1. It indicates the onset of clinical systole of the ventricles.
2. The duration and intensity of the first sound indicates the condition of
myocardium. If myocardium is weak, first heart sound is short and low
pitched. It is prominent when there is hypertrophy of myocardium.
3. Normal first sound also indicates that A-V valves are properly closing.

The second heart sound is due to closure of semilunar valves. It is of higher

frequency than the first sound because of : a) tautness of the semilunar valves in
comparison with A-V valves and b) greater elastic co-efficient of arteries in
comparison with the much looser ventricular chambers.
Thus second heart sound is of hihger frequency, sharp and of short duration
(0,11 sec). It is like a word DUP. The intencity of the sound depends on blood
pressure. Sometimes two valves, aortic and pulmonary do not close simultaneously
during inspiration. This causes splitting of second sound during inspiration.
Significance
1. It indicates end of systole and beginning of diastole of the ventricles.
2. Clear second sound indicates that the semilunar valves are closing properly.
3. Interval between first and second sound is shorter and it indicates clinical systole.
The interval between second heart sound and the next first heart sound is longer and
it indicates clinical diastole of the heart.

The third heart sound. Occasionally a very weak rumbling third heart sound is heard
at the middle third of the diastole. It does not appear until middle third of diastole
because in early part of the diastole the heart is not filled with blood sufficiently to
create even small amount of elastic tension in the ventricles. The frequency of this
sound is low and sometimes so low that it cannot be heard, yet it can be recorded in the
phonocardiogram. It’s duration is 0,04 second.

The fourth heart sound. It is also called atrial sound and is caused by in-rushing of
blood into the ventricle when atria contract which initiates vibrations similar to those
of the third heart sound. It has a very low frequency, i.e. below 20 cycles/second.
Therefore it can never be heard with help of stethoscope but it can jnly be recorded by
phonocardiogram.