Electrocardiogram (ECG)

- Every large square contains 25 small squares (5*5)

- Vertical dimension represents voltage amplitude in millivolts (m.V), and every small square
equals 0.1 m.V
 Ex: in Ventricular Hypertrophy there will be large amount of electricity, and so the voltage
amplitude will be high
- Horizontal dimension represents duration in seconds, and every small square equals 0.04 sec

- Normal pathway of electricity (impulses): SA node > AV node > Purkinje fibers > Ventricles

- P wave: represents atrial depolarization (contraction)

- P-R interval: represents delay in AV node
- QRS complex: represents ventricular depolarization (contraction)
- ST segment: represents isoelectric period (electrical inactivity)
- T wave: represents ventricular repolarization

- We have 12 leads:
 Limb leads: 6 leads detect electricity in the frontal plane. They are lead I, II, III, aVR, aVL, aVF
 Chest leads: 6 leads detect electricity in the horizontal plane. They are lead V1-V6
 When we say inferior leads, we mean lead II, III, aVF

- Golden rule: if electricity is toward the lead, it will give positive deflection. If it is away from it, it
will give negative deflection.

What do we mean by Rhythm? Regular or Irregular

- If regular:
1) Atrial fibrillation (AF)
2) Premature multiple contractions (PMC)

- Atrial fibrillation:
 It is totally irregular. There are multiple foci in the atria, so AV node prevents beats from going
to the ventricles to protect them.
 Ventricular rate may be normal, but atrial rate will be high (400-600)
 No full atrial contraction, so there will be no P waves. Instead, fibrillatory waves (f waves)
present.
 R-R intervals are different
 - Premature multiple contractions:
 May arise from atria or ventricles
 P waves present
 Atrial premature contractions (APC): It is a benign condition. Ventricles are normal and
electricity goes through bundles, so there will be narrow QRS complex
 Ventricular premature contractions (VPC): It is a serious condition since it may switch to
ventricular fibrillation. Electricity goes through muscles (not bundles), so there will be wide QRS
complex

How do we measure Heart Rate (HR)?

- If regular rhythm: HR = 300/ # of big squares between 2 QRS

- If irregular rhythm:
HR = 30 * # of QRS in 10 big squares OR
HR = 15 * # of QRS in 20 big squares OR
HR = 10 * # of QRS in 30 big squares

- Normal HR: 60-90 beats/min

- Sinus tachycardia:
- It may be due to
 Running
 Physiological response to hypovolemia
- Pattern of ECG will be normal; P wave presents before every QRS complex
- HR will be >90 but <120 (SA node will not give more than 120 beats)

- Supraventricular tachycardia (SVT):

- Impulses are not from SA node but from AV node
- Normal QRS complexes but P waves are of unusual shapes (but present before every QRS
complex)

- Ventricular tachycardia:
- Electricity goes through muscles not bundles
- Wide bizarre QRS complexes

- Sinus bradycardia:
- It occurs in athletes or due to drugs
- Normal ECG pattern but HR will be 50
- AV Nodal (Junctional) Rhythm:
- SA node doesn’t produce impulses but AV node produces
- Normal QRS complexes but:
 If the impulses are conducted simultaneously to the ventricles and atria, there will be no P
waves (they disappear beyond QRS complex)
 If the impulses are conducted to the atria then to the ventricles, P waves present but will be
inverted (in lead II)
- HR will be 40-50

Normally AV Nodal Rhythm

SA SA

AV AV

- Idioventricular rhythm (IVR)

- Foci are in the ventricles
- Electricity goes through muscles not bundles
- Wide QRS complexes
- There will be AV dissociation: atria work alone and ventricles alone
- P-P intervals are different from R-R intervals
- HR = 30 (bradycardia)
 Note: if the focus is immediately below AV node, electricity goes through bundles and so normal
QRS complexes. But still P-P intervals are different from R-R intervals

- CHB = complete heart block = AV node complete block

- Sick Sinus Syndrome (SSS): Alternative sinus tachycardia and sinus bradycardia. There is a
possibility that SA node stop working

- Normal axis of the heart is down to the left

 - Leads I and III will be positive. We depend on them to determine the cardiac axis

- If right axis deviation (RAD), lead I will be negative and lead III will be positive
- If left axis deviation (LAD), lead I will be positive and lead III will be negative
- If extreme right or left deviation (NML), both leads are negative

- In right ventricular hypertrophy (RVH), there will be RAD as well as that V1 will be positive
- In pulmonary embolism (PE), there will be pressure on the right side and so RAD
- In ventricular tachycardia, there will be axis deviation but depends on the location of focus

P wave
- Contraction of the atria
- Normally: not more than 2.5*2.5 small squares
- Lead II will be typical positive
- Lead aVR will be typical negative

What do we comment on P wave?

 Existence
 Duration
 Amplitude
 Number
 Dropped beats
 Direction
 Shape in the same lead
 P terminal force in V1

- Left atrial hypertrophy (LAH):

- Occurs with mitral stenosis
- P wave will be broad and bifid
- It is called P-mitrale

- Right atrial hypertrophy (RAH):

- Occurs with pulmonary stenosis or tricuspid regurgitation
- Duration of P wave will be normal, but voltage amplitude will be >2.5 m.V
- It is called P-pulmonale
 - Atrial flutter:
- Full P wave activity but called F waves
- It is regular (R-R intervals are the same)
- It may have 3:1 rhythm (3 F waves then QRS complex) or 2:1 rhythm (2 F waves then QRS
complex)
- Saw-teeth appearance

- Dropped beats: very serious condition (explained later)

- Multi focal atrial tachycardia (MFAT):

- Occurs in COPD and hypoxemia
- Different shapes of P waves in the same lead

- P terminal force in V1: occurs in LAH

QRS complex
- Q wave: the 1st negative wave after P wave and not preceded by any other deflections (waves)
- R wave: the 1st positive deflection after the Q wave
- S wave: the 1st negative deflection following a positive one

- Represents ventricular depolarization

- Duration: not more than 0.11 seconds (less than 3 small squares)
- Voltage amplitude increases normally from V1 (predominantly negative) to V6 (predominantly
positive)

What do we comment on QRS complex?

 Voltage
 Duration
 Q wave
 - In left ventricular hypertrophy (LVH)
- V1 will be more negative
- V5 and V6 will be more positive
- The negative S in V1 plus the positive R in V5 or V6 will be greater than 35 small squares

- In right ventricular hypertrophy (RVH)

- Electricity will be more towards the right
- V1 will be positive
- In V5 and V6, S wave will be more negative

- Low voltage ECG:

- Electricity that reaches the leads is low
- QRS voltage amplitude is less than 10 small squares in all chest leads OR less than 5 small
squares in all limb leads
- It may be due to:
 Severe obesity
 Large left pneumothorax
 Emphysema
 Pericardial effusion
 Acute myocardial infarction (AMI)

QRS duration
- Normally: less than 3 small squares
- Wide: more than 3 small squares

- Causes of wide QRS complex:

1) Ectopic focus in the ventricle:

A. Ventricular premature contractions (VPC)
B. Ventricular tachycardia
C. Idioventricular rhythm (IVR)

2) Right bundle branch block (RBBB)

 Detected in V1
 Electricity normally goes to the left ventricle through the left bundle, but the right ventricle
receives the impulse from the left ventricle (not through the right bundle). It will take more time
and so wide QRS
 3) Left bundle branch block (LBBB)
 Detected in V6

4) Wolff-Parkinson-White Syndrome (WPWS)

 Here, there is an accessory pathway to the ventricles (independent of AV node), so there is no
AV delay (short PR interval)
 The accessory pathway is presented as delta wave

5) Toxic conduction delay: at the level of purkinje fibers, there is a toxic substance that makes
the delay
 Severe hyperkalemia
 Quinidine toxicity
 TCAD toxicity
 Phenothiazine toxicity

Normal activation of the heart

- In the bundles (interventricular spetum):
- Electricity goes from left to right
- V1 will be positive
- V6 will be negative

 Note: Initial septal q wave in V6 is a normal finding

- In the ventricles:
- Electricity is more towards the left
- V1 will be negative
- V6 will be positive

- RBBB causes:
1. Idiopathic (MCC)
2. AMI
3. Cardiomyopathy
4. Pulmonary embolism (PE)
5. Fibrosis

- To diagnose RBBB: Look at V1. It will be R (+) > S (-) > R’ (+)
 - LBBB causes: almost always pathological (very serious condition)
1. AMI
2. Fibrosis
3. Cardiomyopathy
4. HTN
5. Congestive heart failure (CHF)

- If AMI occurs in left ventricle, there will be a dead area that present like a window. So, V6 will
record electricity directly from the septum then from the right ventricle. This will be presented
as deep Q wave (pathological). The phenomena is called window mechanism.

- More than 1 small square in duration

- Amplitude is at least 25% of the following R wave
- Appears in multiple leads corresponding to a certain cardiac segment
- Appears in leads where Q waves are typically absent
 Note: Q waves are normally seen in V6, aVL, lead I
- Appearance of new Q waves in the ECG of the same patient

T wave
- Represents ventricular repolarization
- Follow the direction of QRS. If QRS is predominantly positive, T wave will be positive
- It is positive in most leads and negative in aVR
- Voltage amplitude is not more than 5 small squares in limb leads OR not more than 10 small
squares in chest leads

- Causes of T inversion:
1. Ventricular ischemia
2. Ventricular strain:
 Systemic HTN
 Pulmonary HTN
 PE

3. Digitalis effect
4. Pericarditis
5. Cerebrovascular accident: As in subarachnoid hemorrhage. The brain contains the cardiac
stimulatory center, and so the balance between sympathetic and parasympathetic will be
affected. So, repolarization will be affected
6. BBB

 Note: Tall peaked T wave appears in hyperkalemia

ST segment
- Normally isoelectric (on the base line)
- If the myocardium is injured (ischemia, infarction, inflammation), resting membrane potential
(RMP) of the injured area will be different from the uninjured area. This difference creates
electrical current between them. This current is directed away from the normal area towards
the injured area.

- If subendocardial injury: depressed ST segment

- If transmural injury: elevated ST segment (convex upward)

- If acute pericarditis: elevated ST segment (concave upward)

- If electrically silent infarction: ECG is normal

- If digitalis effect: scooping of ST segment (no acute angle as in ischemia)

- If there is early repolarization variant (as in young black healthy men), ST segment will be
elevated especially in V1, V2, V3. This is normal.

PR interval
- Indication of AV conduction time or AV delay
- Measured from the beginning of P wave to the beginning of R wave
- Normally 3-5 small squares

- 1st degree heart block: there are long PR intervals but with constant duration

- 2nd degree heart block:

1) Mobitz type I block or Wenckbach phenomenon

 Gradual prolongation of PR intervals followed by non-conducted P wave (dropped beat)

2) Mobitz type II block

 Occasional non-conducted P waves
 Almost always pathological
 Occurs in AMI
 May reach complete heart block, so there is need for pacemaker
 - Complete heart block (CHB):
 Complete AV dissociation as the ventricles follow IVR while atria follow an atrial focus
 P-P intervals are different from R-R intervals

- In cases of inferior wall MI, there is irritation of vagal nerve endings that present in the inferior
border of the heart. Vagal stimulation will lead to inhibition of AV node. The 1 st degree block
may be converted to 2nd and then 3rd degree block. So they give the patients atropine

Acute MI

- 3 cardinal features:
A. Deep Q waves
B. Elevated ST segment (measured from J point)
C. Inverted T wave

- Anterior wall MI: Typically, in chest leads

 V1, V2: septal
 V3, V4: anterior wall
 V1, V2, V3, V4: anteroseptal
 V5, V6: lateral wall
 V3, V4, V5, V6: anterolateral
 All leads: extensive anterior wall MI

- Inferior wall MI: in lead II, III, aVF

- Posterior wall MI: changes in anterior leads (V1, V2) are the opposite of changes that happen
with anterior wall MI
 Positive R wave instead of Q wave
 Depressed ST segment instead of elevated

- Non-Q wave infarction:

 Occurs in subendocardial infarction. There will be no full window and so electricity not directly
detected from the septum.
- Old MI:
 There is no current of injury
 Window is present and so deep Q wave
 No ST elevation