Department III, Discipline of Physiology

Physiology of the
cardiovascular system

Practical Lab
MORPHOLOGY OF THE ECG ELEMENTS

2020 - 2021 Ş.l. Dr. Daciana Nistor

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As. Univ. Dr. Nilima Kundnani
 CONTENTS
1. GRAPHICAL ELEMENTS OF A NORMAL ELECTROCARDIOGRAM
1.1. Waves
1) P wave
2) QRS complex
3) T wave
4) U wave
1.2. Segments
1) PQ segment
2) ST segment
1.3. Intervals
1) PQ/PR interval
2) QT interval
3) ST interval
4) RR interval
2. Practical exercise
3. Clinical application
4. Multiple choice questions 2
 OBJECTIVE

The student must know:

1. To recognize the graphical elements of a normal ECG
2. To recognize on ECG the normal P wave
3. To recognize and characterize on ECG the normal QRS complex
4. To recognize and characterize on ECG the normal T wave
5. To recognize and characterize on ECG the normal U wave
6. To recognize and characterize on ECG the normal PQ segment
7. To recognize and characterize on ECG the normal ST segment
8. To recognize and characterize on ECG the normal PQ interval
9. To recognize and characterize on ECG the normal QT interval
10. To recognize and characterize on ECG the normal ST interval
11.To recognize and characterize on ECG the normal RR interval

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 1. GRAPHICAL COMPONENTS OF A NORMAL ECG

1.1. Waves – the deflection is located either above or below the isoelectric
line, characterized by:
− shape
− direction: (+) if situated above the isoelectric line
(-) if situated below the isoelectric line
− duration – expressed in seconds
− amplitude (mV) – arithmetic sum of the components (+) and (-)
1.2. Segments – isoelectric line between the 2 waves, characterized by:
− Position compared to isoelectric line
− duration - expressed in seconds
1.3. Interval – association of a wave and a segment, characterized by:
− duration - expressed in seconds

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 1.1. ECG waves
1) P wave

• Significance: atrial depolarization

− The vector of atrial depolarization is oriented: up → down, right (RA) →
left (LA), posterior → anterior
− Vector of right atrium (RA) is more vertical and oriented slightly forward
− Vector of left atrium is more horizontal and is oriented slightly backward

• Aspect: round and symetric

• Duration: 0,06 - 0,10 s
• Amplitude: < 0,25 mV (maximum in lead II as the vector of atrial
depolarization is almost parallel to the lead II) 5
• Electrical axis in frontal plane: 0 - 75°
 1) P wave

• Direction:
− (+) in majority of the leads (I, II, V4-6, aVF)
− (-) in aVR – depolarization wave moves away from the R (+) electrode
− Sometimes biphasic in V1(exploratory electrode is placed closer to the
atria)
• The first phase (+) is generated by right atrial depolarization
• The second phase (-) is generated by the left atrial depolarization

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 1) P wave

Pathologic modifications:
• In atrial hypertrophy: P wave is wider, longer in duration and with a
modified aspect:
a) Right atrial hypertrophy → “P pulmonale” wave:
- tall, sharp, specially in right leads II, III, aVF
- Biphasic, with initial positive portion much wider in V1
b) Left atrial hypertrophy → “P mitral” wave:
− Bifid in left leads I, aVL, V5, V6
− Biphasic, with the terminal negative portion much wider in V1

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 1) P wave

• In the presence of an ectopic focus, P wave is replaced by a pathologic

wave:
− In atrial fibrillation: P wave is replaced by, small, irregular "f« waves

− In atrial flutter: P wave is replaced by regular saw tooth "F« waves

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 2) QRS complex

• Significance: Ventricular depolarization

• In limb leads:
• Interventricular septum is the first zone to be activated in the entire
ventricular myocardium, it depolarises from left to right and from bottom
towards the top  Q wave
• Zones that are further activated: the apex and lateral walls of the ventricle,
from endocardium towards epicardium, the resultant vector from right to
left and from top to bottom R wave
• The last zone to depolarize is the base of the ventricles, which are activated
from bottom to top and left to right  S wave

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 2) QRS complex

• Significance: ventricular depolarization

b) In precordial leads:
• in V1, V2 (right precordial leads):
− R wave = right ventricular depolarization
− S wave = left ventricular depolarization
• in V5, V6 (left precordial leads):
− R wave = left ventricular depolarization
− S wave = right ventricular depolarization
− Q wave = interventricular septum depolarization

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 2) QRS complex

• Direction:
− First negative wave: Q wave
• duration < 0,04 s; if > 0,04 s → necrosis
• amplitude < 1/4 R (III, aVF, V5-V6)
• absent in V1-V4
− First positive wave: R wave, present in majority of the leads
− Second negative wave or the first negative wave after R wave: S wave

• Duration: 0.08 – 0.10 s

• Amplitude: 1 – 1.5 mV (10 - 15 mm)

− minimum 0,5 mV in leads I, II, III
− minimum 1 mV in precordial leads

• Electrical axis in the frontal plane: -30o → +110o

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 2) QRS complex

Intermediate axis: +30o → +60o

I aVR

II aVL

III aVF

Axis is  with a lead having maximum projection on it

Axis ⊥ to a lead having minimum projection on it (0). 12
2) QRS complex

Vertical axis: +60o → +110o

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2) QRS complex

Horizontal axis: -30o → +30o

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 2) QRS complex
• Aspect:
• monophasic (a), biphasic (b) and (c) or triphasic (d)
• A particular aspect in precordial leads → transition phenomena: amplitude of
R wave ↑ from V1 to V6, while the amplitude of S wave ↓ from V1 la V6:
- in V1, V2: R (RV depol.) < S (LV depol.), Q wave does not exist
- in V3, V4 (transition zone): R=S, Q wave does not exist
- in V5, V6: R (LV depol.) >S (RV depol.), Q wave exists (IVS depol.)
• Sokolov-Lyon index:
− normal: SV2 + RV5 < 35 mm or RV1 + SV6 < 10,5 mm
− useful in diagnosis of ventricular hypertrophy

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 2) QRS complex

Pathological modifications:
• In ventricular hypertrophy: QRS complex = 0.10-0.12s has modified aspect
a) Left ventricular hypertrophy (LVH)
− aspect “rS” in V1, V2 and aspect “Rs” in V5, V6
− Sokolov-Lyon index: SV2 + RV5> 35 mm
− Modified in repolarization phase (negative T wave, assimetric and ST
segment depression) in V5, V6

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 2) QRS complex

b) Right ventricular hypertrophy (RVH):

− aspect “Rs” in V1, V2 and aspect “rS” in V5, V6
− Sokolov-Lyon index: RV1 + SV6 > 10,5 mm
− Secondary modifications of repolarisation (asymetric negative T waves
and ST depression) in V1, V2

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 2) QRS complex

Pathologic modifications:
• In RBBB and LBBB: QRS complex has similar aspect as seen in ventricular
hypertrophy, but duration is > 0.12s

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 3) T wave

• Significance: ventricular repolarization (epicard →

endocard)
• Aspect: rounded, asymetric, with ascending slope more
gradual and an abruptly descending slope
• Direction: aVR
− concordant with QRS complex
− positive in most of the leads, negative in aVR
• Amplitude: < 1/3 QRS (< 6 mm)
• Duration: 0,13 - 0,30 s
• Physiological variations:
− Sensitive to physiological modifications: amplitude
increases in vagotomy subjects (PNS stimulation)
− (-) in all leads in a new born child, later it starts getting
positive from V6 to V1
− “JuvenileT wave”, (-), asymmetric, flat, in V1-V3
(specially in females < 40 ani)
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 3) T wave

Pathological modifications:
• ischemia:
− T wave sharp and symmetrical
− Positive in sub endocardial ischemia
− Negative in sub epicardial ischemia

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 3) T wave

Pathological modifications:
• Hypopotassemia: flat T waves, ST segment depression, appearance of U
wave
• Hyperpotassemia: Tall and sharp T waves, flat P wave, enlarged QRS
complex, prolonged PQ interval

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 3) T wave

Pathologic modifications:
• Hypocalcemia: prolonged QT interval, ST elevation, flat or negative T wave
• Hypercalcemia: shortening of QT interval, wide QRS complex, ST elevation,
appearance of J waves (Osborn waves = supplementary deviation at the
junction between the end of QRS complex and start of ST segment),
appearance of prominent U wave

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 4) U wave

• Significance: Purkinje fiber postdepolarization or papillary muscle

repolarization
• Aspect:
− small, rounded
− More evident on  HR, [K+] 
− better expressed in right precordial leads (V1, V2)
• Direction: similar to that of T wave from the same lead
• Amplitude: < 1/3 of the amplitude of T waves in the same lead

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 1.2. ECG SEGMENTS

1) PQ segment
• Significance: atrial depolarization
• Duration: 0,06 - 0,12 s
Pathological modification:
• Is short in pre-excitation syndrome
• Is prolonged in atrio-ventricular block

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 1.2. ECG SEGMENTS
2) ST Segment
• Significance: the last part of ventricular depolarization and the beginning of
repolarization
• Duration: 0,05 - 0,15 s
• Position relative to the isoelectric line: isoelectric (+/- 1 mm)
• J Point ("junction"):
− represents the end of ventricular depolarization
− is an essential criterion for determining the duration of QRS
− must be identified after the appearance of QRS complex (point of
inflection) in the transition zone, moving from vertical to horizontal
Pathological changes:
• in subepicardial injury: ST elevation
• in subendocardial injury: ST depression

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 1.3. ECG INTERVALS
1) PQ/PR (iPQ/iPR) interval
• Significance:
− AV conduction (includes atrial depolarization, intra-atrial conduction, through
the AV node and His-Purkinje system)
− P wave plus PQ segment (if Q waves are absent, it is known as PR interval)
• Duration: 0.12 – 0.21 s
Pathologic modifications:
• iPQ < 0,12 s Wolff-Parkinson-White (WPW) syndrome: pre-excitation syndrome in
which the ventricular myocardium is excited early by the Kent fascicles, which
establishes a direct connection between the atria's and ventricle, bypassing the AV
node 
− Shortening of AV conduction  short iPQ
− Modification of ventricular activation sequence  generation of positive R
waves in the beginning – delta waves  prolonged QRS complex
− Modified ventricular repolarization (terminal phase modifications)

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 1) PQ/PR (iPQ/iPR) interval

• iPQ > 0,24 s caused by:

• Increased vagal tone
• Pharmacologic action of some drugs (β-blockers)
• Different degrees of AV block:
− First-degree AV block – all P waves are followed by QRS complex, with
enlarged but constant PR interval

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 1) PQ/PR (iPQ/iPR) interval
− Second-degree AV block
• Mobitz type I – progressive elongation of PR interval, until a P wave is
blocked (interval consists of two blocked P waves = Luciani-Wenckebach
interval)
• Mobitz type II – intermittent blockage of P wave, systematized (fixed
atrioventricular ratio), and the PR intervals of the conducted P waves are
constant and normal

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 1) PQ/PR (iPQ/iPR) interval

− Third-degree AV block – none of the atrial impulses are transmited to the

ventricles, hence there is no connection between P waves and QRS  atrio-
ventricular dissociation

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 2) QT interval
• Significance:
− Consists of QRS complex, ST segment, and T wave
− Ventricular depolarization & repolarization  electrical ventricular
systole
• Duration:
− Varies on the basis of HR
− Values can be corrected based on HR (QTc), according to Bazett formula:
QTc = QT(s)/√RR(s)
− Normal value of QTc is 0.35 – 0.45 s
Pathological modifications:
• Short QT interval (A) – hypercalcemia
• Long QT interval: > 0.44 s in males and > 0,46 s in females (B) -
hypocalcemia, congenital (long QT syndrome)

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 3) ST interval

• Significance:
− Consists of ST segment and T wave
− Last phase of ventricular depolarization and ventricular repolarization
(terminal phase)
Pathological modifications = terminal phase modifications:
• In ischemic cardiopathy (lesions and ischemia) discordant terminal phase
changes appear, characterized by ST depression in opposite direction
compared to T wave:
− In lesions and sub-epicardium ischemic ST elevation and symmetric,
wide and negative T waves appear
− In lesions and sub-endocardium ischemia ST depression and symmetric,
wide positive T waves appear
• In ventricular conduction disturbances (bundle branch blocks, ventricular
hypertrophy, WPW syndrome) concordant modifications of terminal
phase appear characterized by ST depression and negative T wave
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 4) RR (iRR) interval

• Significance:
− Is the interval between two successive QRS complexes
− Duration of one cardiac cycle
− Useful for determining HR:
60 60 1500
HR (b/min) = = =
iRR (s) iRR (mm) x 0.04 iRR (mm)
• Duration: varies and is inversely proportional to HR (la HR=75 bpm,
iRR=0.80 sec)

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 2. PRACTICAL EXERCISE

Complete the table by performing morphological and chronological

analysis of the below given ECG:

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 2. PRACTICAL EXERCISE

ECG Significance Aspect Direction Duration Amplitude

components

P wave

QRS complex
in limb leads
QRS complex
in precordial
leads

T wave

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 2. PRACTICAL EXERCISE

ECG Significance Position in relation Duration

components to isoelectric line
PQ segment

ST segment

ECG Significance Components Duration

components
PQ interval

ST interval
QT interval

RR interval

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 3. CLINICAL APPLICATION

1. A 50 year old male with nausea presented to the emergency service. ECG
was recorded and the standard lead II findings are given below. State the QT
interval for this case?
A. 0,12 s
B. 0,16 s
C. 0,22 s
D. 0,30 s
E. 0,48 s

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 3. CLINICAL APPLICATION

• QT interval: electrical ventricular systole (EVS), includes ventricular

depolarization and repolarization
• iQT = 12 (mm) x 0,04 (s/mm) = 0,48 s  correct answer E

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 3. CLINICAL APPLICATION

2. If the ventricular depolarization wave moves to -60° in the frontal plane, in

which lead will it give rise to a large negative wave?
A. aVR
B. aVL
C. DII
D. DIII
E. aVF

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 3. CLINICAL APPLICATION
_
-90°
-60°
I
aVR aVL aVR aVL
-30°

0° I
II III
+30°

+120° +60°
+90°
+ III II
aVF aVF
• For a wave to be wide, the vector that characterizes it should be parallel to
the lead
• -60° corresponds to lead DIII  vector is parallel to lead III
• Positive part of the lead III has +120° axis
• Negative part of the lead III has -60° axis
• The vector is directed towards (–) lead  wave is negative  correct 39
answer D
 3. CLINICAL APPLICATION

3. If the ventricular depolarization wave shifts towards -30° in frontal plane in

which lead will it give rise to a large positive wave?
A. aVR
B. aVL
C. Lead I
D. Lead II
E. aVF

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 3. CLINICAL APPLICATION
-90°
-60°
I
aVR aVL aVR aVL +
-30°

0° I
II III
+150° +30°
-
+120° +60°
+90°
III II
aVF aVF
• For a wave to be wide in a lead, the vector that charecterizes it should be
parellel to the lead
• -30° corresponds to lead aVL  vector is parallel to aVL
• Positive part of the aVL lead has -30° axis
• Negative part of the aVL lead has an axis of +150°
• Vector is directed towards (+) lead  wave is pozitive correct answer B41
 3. CLINICAL APPLICATION
4. A 65 year male suffered a car accident and was transported to the ER.
Clinical assesment revealed blood pressure 160/80 mmHg and ECG given
below.

Which would be PQ interval of this patient?

A. 0.07 s
B. 0.10 s
C. 0.16 s
D. 0.20 s
E. 0.24 s

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 3. CLINICAL APPLICATION

PQ

PQ interval = 4(mm) x 0.04 (s/mm) = 0.16 s  correct answer C 43

 3. CLINICAL APPLICATION
5. A 65 year male suffered a car accident and was transported to the ER.
Clinical assesment revealed blood pressure 160/80 mmHg and ECG given
below.

State the HR of this pacient

A. 64 beats/min
B. 74 beats/min
C. 88 beats/min
D. 94 beats/min
E. 104 beats/min

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 3. CLINICAL APPLICATION

• HR is determined by the formula:

60 60 1500 1500
HR = = = = = 88b / min
i RR( s ) i RR( mm ) x0,04 i RR( mm ) 17 (mm )
 Correct answer C
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 4. MCQ’s
Note: questions marked with * have only one correct answer, the others have
2 or 3 correct answers.
1. Which of the following statements are true regarding normal P wave:
A. Represents atrial depolarisation which takes place from top to bottom
and from right to left
B. Best seen in precordial leads
C. Best seen is lead II because the atrial depolarization vector is parallel to
lead II
D. Is negative in aVR because the atrial depolarization vector moves toward
the positive electrode of the lead
E. Is always positive in aVR
2. Which of the following statements are true regarding a normal QRS
complex:
A. Represents ventricular repolarization
B. Represents ventricular depolarization
C. Hold equal significance in limb and precordial leads
D. Amplitude is used to determine the electrical axis
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E. Has same aspect in all leads
 4. MCQ’s

3. Regarding the normal QRS complex the following statements are false:
A. In V1, V2, R wave represents RV depol., while S wave represents LV
depol.
B. In V5, V6, R wave represents LV depol., while S wave represents RV
depol. And Q wave represents depol. of IV septum
C. Normal axis of QRS complex is between -30° şi +110°
D. Normal axis of QRS complex is between 0° şi +90°
E. The mere presence of QRS complex in all leads define sinus rhythm

4. *Characteristic of T wave:
A. Represents ventricular repol. Which occurs from epicardium to
endocardium
B. Represents ventricular repol. Which occurs from endocardium to
epicardium
C. Is rounded and symmetric
D. Is followed by a QRS complex
E. It must have an amplitude at least equal to that of the QRS complex 47
 4. MCQ’s

5. *The following are the characteristics of a normal U wave, except

A. Represents the repol. Of the papillary muscles or post-depolarization of
Purkinje fibers
B. Is small, rounded and is more prominent in reduced HR, in
hypopotassaemia
C. Is well expressed in right precordial leads (V1, V2)
D. Have same direction as T wave in same lead
E. It has an equal amplitude equal to that of T wave in the same lead

6. Regarding PQ segment, which of the following statements are true:

A. Represents the state of complete atrial depol.
B. Has duration of 0,06 - 0,12 s
C. Is short in AV block
D. Is enlarged in pre-excitation syndrome
E. Duration holds no importance
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 4. MCQ’s

7. The following statements are true regarding normal ST segment, apart from
2 exceptions. Which are those?
A. Represents the last part of ventricular depol. and starting of ventricular
repol.
B. Has a duration of 0,05 - 0,15 s
C. Normally it is isoelectric
D. In sub epicardial lesions the ST depression is noted
E. In sub endocardial lesions ST elevation is noted

8. Which of the below mentioned statements are correct regarding PQ

interval:
A. Represents the atrioventricular conduction
B. Has a normal duration of 0,12 - 0,21 s
C. Is prolonged in pre-excitation syndrome
D. Is short in AV block
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E. Is short in increased vagal tone
 4. MCQ’s

9. Which of the following statements are true regarding QT interval:

A. Represents the electrical ventricular systole that included ventricular depol.
and ventricular repol.
B. Duration depends on HR
C. Duration is not influenced by HR
D. Is short in hypocalcemia
E. Is prolonged in hypercalcemia

10.Select the correct options regarding the RR interval:

A. It is equal to the duration of a cardiac cycle
B. Is used in determining the HR
C. It varies, is directly proportional to HR
D. It varies, is inversely proportional to HR
E. If HR = 75 b/min then RR interval = 1 s
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 Take home messages!

• Knowing the normal characteristics of the ECG components (waves,

segments, intervals) is essential for differentiating between the normal and
pathological electrocardiogram!

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