Electrocardiography

Oscar Payawal Jr., MD, FPCP, FPCC

Internal Medicine-Cardiology
Invasive Cardiology
 Electrocardiography

▲  graphic recording of electric potentials produced

by the heart
▲  signals detected by metal electrodes attached to
extremities and chest wall and recorded by the
ECG machine
▲  noninvasive, inexpensive and readily available
Resting or Polarized State (Phase 4)

-
 Depolarization-Repolarization Cycle
(Action Potential)
Phase 0 : Rapid depolarization
●  Na moves rapidly into the cell
●  Ca moves slowly into the cell

Phase 1: Early repolarization

●  Na channels close
●  Transient efflux of K
Phase 2: Plateau phase
●  Ca continues to flow in
●  K continues to flow out

Phase 3: Rapid repolarization

●  Large amounts of K diffuse out as all K channels open
●  Inactvation of Ca channels
Phase 4: Resting Phase
●  Na-K pump restores Na out
●  Cell membrane impermeable to Na ions
 Einthoven Triangle Hypothesis

Assumptions:
●  Roots of the LA, RA, LL form apices of a triangle.
●  Electrical forces produced by the heart are represented
by an equivalent dipole at the center of the triangle.
● Body tissues and fluids in which triangle is located act as
homogenous conductor.
● Bipolar limb leads record potential variations of the heart
in the frontal plane.

Einthoven’s Law: Lead I + Lead III = Lead II

 Unipolar Precordial Leads

V1 - 4th ICS right sternal margin

V2 - 4th ICS left sternal margin
V3 - midway between V2 and V4
V4 - 5th ICS MCL
V5 - AAL same level as V4
V6 - MAL same level as V4
Leads View of Heart
LI Lateral wall
LII Inferior wall
LIII Inferior wall
AVR No specific view
AVL Lateral wall
AVF Interior wall
V1 Anteroseptal wall
V2 Anteroseptal wall
V3 Anterior wall
V4 Anterior wall
V5 Lateral wall
V6 Lateral wall
 P wave
●  represents atrial depolarization
●  atrial conduction time
●  normal amplitude is 0.5 to 2.5 mm
●  normal duration is up to 0.10s in adults
●  usually biphasic in V1
 P-R Interval

●  represents time interval for impulse to reach

ventricles from SA node
●  measured in limb lead with longest PR interval
●  normal is 0.12-.20s in adults (HR = 70-90/min)
 QRS Complex
Q wave - initial downward deflection
R wave - first upward deflection whether preceded by a
Q wave or not
S wave - downward deflection following the R wave
QS wave - single negative deflection representing entire QRS
R’ wave - second upward deflection
S’ wave – downward deflection following the R’ wave
 ST Segment
●  represents period from end of ventricular depolarization
to start of ventricular repolarization
●  between end of QRS and start of T wave
●  clinically important if elevated or depressed as it
may represent infarction or ischemia
●  usually isoelectric but may me depressed –0.5 mm
or elevated by 1mm.
S-T depression
 T wave
●  represents ventricular repolarization
●  usually upright in LI, LII and diphasic
or inverted in LIII, V1
●  maybe inverted up to V3 in young adults
●  T wave in V6 usually > V1
●  physiologic T wave changes maybe seen in
body position, fever, skeletal abnormalities,
hyperventilation , fever, etc.
 Q-T Interval
●  represents electrical systole
●  time required for ventricular depolarization
and repolarization
●  varies with age sex and heart rate
●  normal QT is 0.35-0.44s in adults
●  Corrected QT or QTc
Q-Tc = Q-Ts
R-R interval (s)

●  Prolonged QTc > 0.425s

 U wave
●  small deflection after the T wave
●  represents repolarization of the Purkinje fibers
●  tallest in V2 & V3
●  usually does not exceed >1mm in amplitude
●  same as T wave polarity
●  increased amplitude in LVH, hypokalemia, drugs etc.
●  negative U wave specific for heart disease
 Left Atrial Hypertrophy

●  P wave duration > 0.12s

●  Biphasic P wave in V1 & V2 with negative
terminal portion having depth of >0.1 mV
LII

V1
 Right Atrial Enlargement

●  P waves tall (> 0.25mV) & peaked

in inferior leads
●  Biphasic P wave in V1 with first component
larger than the second
Right Atrial Enlargement
Right Atrial Enlargement
Right Ventricular Hypertrophy
●  R/S ration in V1 > 1
●  S in V1 < 2mm
●  RAD > 110 degrees
Right Ventricular Hypertrophy
Left Ventricular Hypertrophy

●  Sum of R wave in V5 or V6 +
S wave in V1 or V2 > 35mm
in adults > 30 years
(>40 mm in 20-30 years &
>60 mm in 6-20years )