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Journal of Electrocardiology 48 (2015) 1 – 7
www.jecgonline.com

Surface 12 lead electrocardiogram recordings using smart

phone technology
Giselle A. Baquero, MD, a Javier E. Banchs, MD, b Shameer Ahmed, MD, a
Gerald V. Naccarelli, MD, a Jerry C. Luck, MD a,⁎
a
Penn State Hershey Heart & Vascular Institute, Division of Cardiology, Department of Medicine, Penn State College of Medicine,
Penn State University, Hershey, PA
b
Texas A & M College of Medicine, Baylor Scott & White Health, Temple, TX

Abstract Importance: AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a
single channel (lead I) ECG rhythm strip using an iPhone. In the past few years, the use of
smartphones and tablets with health related applications has significantly proliferated.
Objective: In this initial feasibility trial, we attempted to reproduce the 12 lead ECG using the
bipolar arrangement of the AliveCor monitor coupled to smart phone technology.
Methods: We used the AliveCor heart monitor coupled with an iPhone cellular phone and the
AliveECG application (APP) in 5 individuals.
Results: In our 5 individuals, recordings from both a standard 12 lead ECG and the AliveCor
generated 12 lead ECG had the same interpretation.
Conclusions: This study demonstrates the feasibility of creating a 12 lead ECG with a smart phone.
The validity of the recordings would seem to suggest that this technology could become an important
useful tool for clinical use. This new hand held smart phone 12 lead ECG recorder needs further
development and validation.
© 2015 Elsevier Inc. All rights reserved.
Keywords: AliveCor ECG; Electrocardiogram; 12 lead; Smart phone ECG

Introduction ECG using the bipolar arrangement of the AliveCor monitor

The standard 12 lead electrocardiogram (ECG) has been
used clinically for over 100 years for the diagnosis of ischemic
heart disease and cardiac arrhythmias [1–3]. New technology
today allows for a standardized single lead recording to be
obtained by a computerized monitoring bipolar device that is
coupled and wirelessly connected to a smart phone [4–7].
The standard bipolar limb leads of the 12 lead ECG can be
theoretically reproduced with simple bipolar connections of the
limbs according to Einthoven's triangle [1,2]. The augmented
interpolated limb leads (VR, VL, VF) can also be re-created
theoretically by connecting the exploring electrode to the focus
limb and the other two limbs to the negative pole of the
recording bipolar device [3]. Similarly, the chest leads can be
created with a bipolar arrangement: the positive electrode is on
the chest (at V1, V2, V3, V4, V5, V6) and the distant negative
electrode is on the lower left leg, at a distance from the heart. In
this initial feasibility trial, we attempted to reproduce the 12 lead
⁎ Corresponding author at: 500 University Drive, P.O. Box 850. H047,
Hershey, PA 17033–0850.
E-mail address: jluck@hmc.psu.edu
http://dx.doi.org/10.1016/j.jelectrocard.2014.09.006
0022-0736/© 2015 Elsevier Inc. All rights reserved.
coupled to smart phone technology.
Methods
Patient population
We used the AliveCor heart monitor coupled with an
iPhone cellular phone and the AliveECG application (APP).
The population for this smart phone 12-lead ECG feasibility
study included 5 individuals: two normal individuals with a
narrow QRS complex and three with a wide QRS complex:
one each with right bundle branch block, left bundle branch
block, and dextrocardia (Table 1). Each of these individuals
had a standard 12 lead ECG performed with a MAC5500,
multichannel ECG machine. In case #1 with a narrow QRS
and case #2 with a left bundle branch block, the standard 12
lead ECG and the smart phone created ECG were recorded at
the same sitting and using the same electrode placements on
the arms, left lower leg just above the ankle and the
precordial leads. Case #3 is a healthy competitive cyclist
who had the smart phone generated 12 lead ECG performed
2 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7

by the authors and one week later had a standardized ECG

performed by a heart station technician. Case #4 had the
standard tracing performed one week prior to surgical LEADS I, II, III
removal of a esophageal cancer and the smart phone tracing
performed on day 4 post operation. Case #5 has dextrocardia RIGHT LEFT
and had the standard tracing on admission for endocarditis - +-
and the smart phone tracing performed 2 days later. -
- +
AliveCor technology and modification
The AliveCor device consist of FDA approved (1)
hardware, a bipolar electrode case that fits on a smart
phone to record the hearts electrical activity and (2) software + +
to process, save and transmit the single lead electrocardio-
gram. An APP on the smart phone (AliveECG) transforms
the electrical signal to ultrasound. The smart phone's
microphone will receive the ultrasound signal and transmit
the electrocardiogram as a wireless PDF format.
LEADS aVR, aVL, aVF
Smart phone ECG recording
RIGHT LEFT
The AliveCor device is a standardized, bipolar single lead +- +-
recorder. Using the principles of Einthoven's triangle, the - - - +
standard ECG bipolar and interpolated limb leads can be
reproduced. To record the standard bipolar limb leads; the
AliveCor case was adapted with adhesive ECG tabs
(Kendall, MT710 Diagnostic Tab Electrodes). These stan- --
dard adhesive tabs are placed on the right and left forearms +
and the lower left leg just above the ankle. The adhesive tabs
are used for the precordial leads (V1, V2, V3, V4, V5, V6)
and are placed on the chest using the standard locations [1,2].
Using three 24 inch insulated wires with mini alligator clips,
the standard bipolar (leads: I, II, III) and interpolated (aVR,
aVL, aVF) limb leads and the precordial leads are recorded LEADS V1-V6
in successive order (Fig. 1). For the augmented limb leads,
we used a positive lead as the exploring electrode and the other RIGHT LEFT

two limb leads are connected to the negative pole. For the six
chest leads, the positive electrode is the exploring electrode
while the indifferent electrode is negative and is located on the
distant left leg. Using the principles of the Einthoven's triangle
and Goldberger modification, the standardized AliveCor ECG
can be modified to obtain a 12 lead ECG recording [2,3].
A standard 12 lead recording was made using a Mac 5500
recorder. In case #1 and case #2, the authors performed the
standard 12 lead recording and used the same exact sites for
the smart phone recording. In case #3, case #4 and case #5,
the standard Mac 5500 12 lead ECG was performed by an
ECG technician. The precordial lead electrode placements
were not exactly the same sites as those used for the
AliveCor recordings that were done at a different setting.
V1 - V6
++
++++
- +
-
Fig. 1. AliveCor ECG recording. Panel A: Bipolar limb lead recordings (I, II, III)
using Einthoven's triangle format. Panel B: Unipolar limb lead recordings
(aVR, aVL, aVF) using the method of Goldberger with the focus exploring
electrode as positive and the other two limbs as the negative. Panel C:
Precordial leads V1–V6: with the positive exploring electrode on the chest
and the negative electrode on the distant lower left leg.

Results of the 5 individual recordings
The clinical characteristics of the 5 individuals in this
feasibility study are described in Table 1.
Case #1 is a 67 year old male with a normal echocardio-
gram, ejection fraction 0.55, normal chamber sizes, and
normal valve function. A standard 12 lead electrocardiogram
(ECG) and then a sequential AliveCor 12 lead ECG are
performed using the same lead tabs on the limbs and chest.
Both the Mac 5500 standard 12 lead ECG and the AliveCor
generated 12 lead ECG have the same interpretation. Both
show sinus rhythm, normal intervals; normal axis + 60
degrees; left atrial abnormality and left ventricular hyper-
trophy by voltage. The AliveCor tracing is a sequential
obtained ECG and demonstrates the presence of a sinus
arrhythmia. In Fig. 2, there are comparisons of the two
tracings. The email PDF transfer of the AliveCor version is
reconstructed for printing the 12 lead. Despite the
 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7 3

Table 1 sequentially obtained AliveCor generated 12 lead ECG are

Clinical characteristics of the study individuals. compared in Fig. 3. The QRS amplitudes, axis, intervals,
Case Age/sex Clinical diagnosis Baseline ECG initial and terminal QRS forces and “P” wave and “T” wave
#1 67/M APC’S, VPC’S Sinus rhythm rate 60; LVH, LAA vectors mimic the standard ECG recording. In the smart
#2 55/M Cardiomyopathy Sinus rhythm rate 96; LBBB phone recording, precordial leads V1, V2 and V3 show
#3 23/M none Sinus rhythm rate 70; normal higher ST elevation than in the Mac 5500 recording.
#4 70/M Esophageal CA Sinus tachycardia rate 116; RBBB
Case #3 is a 23 year old male and is a competitive cyclist
#5 31/M Endocarditis Atrial fibrillation; Dextrocardia
Junctional rhythm rate 71 with a normal echocardiogram, ejection fraction 65%. A
standard 12 lead ECG and the AliveCor generated ECG are
APC’S = atrial premature complexes. VPC’S = ventricular premature
complexes.
performed on two different days. The chest leads position
LAA = left atrial abnormality. LVH = left ventricular hypertrophy. V1–V4 are the same but V5 and V6 are different. Both the
LBBB = left bundle branch block. RBBB = right bundle branch block. standard ECG and the AliveCor ECG have the same
interpretation. They show sinus rhythm, normal intervals,
and a vertical axis. Both are normal ECGs. In Fig. 4, both
reconstruction, the QRS amplitudes, axis, intervals, initial tracings are compared. The limb leads QRS complexes
and terminal QRS forces and “P” wave and “T” wave vectors amplitudes, axis, intervals and initial and terminal forces
are remarkably similar. mimic each other on the standard and AliveCor tracings. The
Case #2 is a 55 year old male with a tachycardia-induced vector of the “P” wave is the same between the two. The
cardiomyopathy secondary to atrial fibrillation with a rapid chest leads V1, V2, V3 and V4 are quite similar but V5 and
ventricular rate. He is now post direct current cardioversion V6 are different given different positions. In the smart phone
and has symptomatic improvement in sinus rhythm. He has recording, precordial leads V1, V2, V3 show J point
an underlying left bundle branch block. A standard 12 lead elevation and ST elevation that is not seen in the Mac
ECG and then the sequential AliveCor 12 lead ECG are 5500 recording.
performed using the same lead tabs on the limbs and chest. Case #4 is a 70 year old symptomatic male with shortness
Both ECG tracings show sinus rhythm, normal PR and QT of breath. There is a prior history of coronary artery disease,
intervals but a wide left bundle branch block QRS complex right bundle branch block and now esophageal carcinoma.
and left atrial abnormality. The standard ECG and the The standard 12 lead ECG is a pre-operation recording and

Fig. 2. Comparison of the standard and device generated 12 lead recordings for case #1: Top trace Mac 5500 12 lead ECG and below AliveCor ECG with normal
standardization at 25 mm/second (S): Interpretation standard: sinus rhythm, rate 60 beats/minute (bpm), normal intervals: PR 0.17 s, QRS duration 0.08 s, QT
0.39 s, QRS axis +60 degrees. Left atrial abnormality, voltage criteria for left ventricular hypertrophy. AliveCor generated ECG from sequentially transmitted
PDF files and then assembled as shown: Interpretation: sinus rhythm and sinus arrhythmia, rate varies 56–71 bpm, normal conduction intervals: PR 0.17 s, QRS
duration 0.08 s, QT 0.4 s, QRS axis +55 degrees. Left atrial abnormality, voltage criteria for left ventricular hypertrophy. A comparison shows a true 12 for 12
ECG lead match in these ECGs recorded nearly simultaneously from the same electrode tabs. A comparison of the QRS, “P” wave and “T” wave amplitudes and
axis is the same between the two ECGs.
4 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7

Fig. 3. Comparison of the standard and device generated 12 lead recordings for case #2: Top trace standard ECG and below device generated ECG: Interpretation standard:
sinus rhythm rate 94 bpm; PR 0.16 s, QRS duration 0.17 s, QT 0.38 s, QRS axis −15 degrees; left atrial abnormality; left bundle branch block with repolarization changes.
Device generated ECG from sequentially transmitted PDF files and reassembled as shown: Interpretation: sinus rhythm, rate 100 bpm; PR 0.16 s; QRS duration 0.16 s; QT
0.4 s; QRS axis −15 degrees. Left atrial abnormality; left bundle branch block with repolarization changes. The comparison shows a true 11 for 12 ECG lead match in these
ECGs recorded sequentially using the same limb and precordial position electrode tabs. Only lead aVF is slightly different.

Fig. 4. Comparison of the standard and device generated 12 lead recordings for case #3: (same format as above): Interpretation standard: sinus rhythm and sinus arrhythmia
rate varies from 62 bpm to 88 bpm, PR 0.12 s, QRS duration 0.11 s, QT 0.4 s, QRS axis +100 degrees. Normal ECG. Device generated ECG interpretation: sinus rhythm
rate 48 bpm, PR 0.12 s, QRS duration 0.10 s, QT 0.4 s, QRS axis +100 degrees. Normal ECG. In this comparison, the limb leads from the two formats mimic each other.
The chest leads, V1, V2, V3 and V4 are the same but leads V5 and V6 are different given the lead placements are different.
 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7 5

Fig. 5. Comparison of the standard and device generated 12 lead recordings for case #4: (same format as above): Interpretation standard: sinus tachycardia, rate
116 bpm, PR 0.15 s, QRS duration 0.16 s, QT 0.38 s, QRS axis − 45 degrees. Left axis deviation; right bundle branch block with repolarization abnormality;
inferior myocardial infarction, age undetermined. Device generated ECG interpretation: sinus rhythm rate 75 bpm, PR 0.18 s, QRS duration 0.13 s, QT 0.4 s,
QRS axis − 45 degrees. Left axis deviation, right bundle branch block with repolarization abnormality, inferior myocardial infarction. Despite the different chest
lead positions and the different days for each, the two are quite similar in most leads.

the AliveCor generated 12 lead is a postoperative recording
with different chest positions. The standard 12 lead ECG
shows sinus tachycardia, rate 116 bpm; wide QRS duration,
normal QT, left axis deviation, − 45 degrees, right bundle
branch block with a repolarization abnormality and an
inferior myocardial infarction, age undetermined (Fig. 5).
The AliveCor generated 12 lead ECG also shows sinus
rhythm, left axis deviation, right bundle branch block and the
age undetermined inferior infarct. Although the tracings are
from different days, there is a remarkable similarity between
the two recordings QRS durations, amplitudes and axis. The
initial and terminal QRS forces and “P” wave vectors are also
similar. There are ST depressions that seem exaggerated in
V1 and V2 in the smart phone recording.
Case #5 is a 31 year old male symptomatic with fever,
malaise, shortness of breath, and a new diagnosis of
endocarditis. He has a long-standing permanent pacemaker
with a trans-venous right atrial pacing electrode and an
epicardial ventricular pacing lead. The base line cardiac
diagnoses are persistent atrial fibrillation, complete atrial-
ventricular block and congenitally corrected transposition of
the great arteries with dextrocardia. The standard 12 lead
ECG and the AliveCor generated 12 lead are from different
days. The standard 12 lead ECG shows underlying atrial
fibrillation, an accelerated junctional rhythm at 72 bpm and
dextrocardia with right axis deviation and poor R wave
progression. In Fig. 6, the AliveCor generated 12 lead ECG
shows atrial fibrillation, an accelerated junctional rhythm
and a comparable QRS morphology that also supports the
diagnosis of dextrocardia. In the smart phone recording,
there are repolarization differences in leads I, II, V1, V2
and V4–V6.
Discussion
The standard 12-lead electrocardiogram remains the
backbone for clinical decision-making in the acute care
arena particularly for diagnosis and treatment of the acute
coronary syndromes. It remains the primary tool for the
recognition of and the diagnosis of cardiac arrhythmia. In
both cases, the earlier the 12 lead ECG can be obtained, the
earlier the diagnosis, initiation of therapy and the reduction
in morbidity and mortality. The new technology is moving
medicine in that direction. The AliveCor single channel
validated and standardized ECG recorder for smart phone
use is a step in the direction of better technology.
We hypothesize from our 5 case series that the device can
be easily modified to become a small, versatile and practical
12 lead ECG recorder. The smart phone is a ubiquitous part
of life today and for it to have the potential to easily record a
simple important medical test such as the 12 lead ECG may
be potentially lifesaving.
In this report, we show the feasibility of converting a
smart phone based bipolar heart rhythm recorder to a 12 lead
recorder with standard ECG tabs and wires with alligator
6 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7

Fig. 6. Comparison of the standard and device generated 12 lead recordings for case #5: (same format as above): Interpretation standard: underlying atrial
fibrillation, a regular wide QRS with a QRS duration 0.12 s (non-specific intra-ventricular conduction delay), QT 0.38 s, QRS axis +150 degrees. An accelerated
junctional rhythm at 72 bpm. There is right axis deviation, poor R wave progression and reduced QRS voltages in the left lateral precordial leads that are
consistent with dextrocardia. Device generated ECG interpretation: Underlying atrial fibrillation, regular wide QRS rhythm, QRS duration 0.12 s, QT 0.44 s,
QRS axis +150 degrees. Accelerated junctional rhythm, at 64 bpm, right axis deviation, poor R wave progression without transition consistent with dextrocardia.
The ECGs are quite comparable despite different precordial lead placement and on different days.

clips from a hardware store. We simply followed the tenets
of Einthoven's triangle to sequentially perform a standard-
ized 12 lead ECG in 5 individuals. The bipolar limb lead
tracings (I, II, III) are easily recorded with the AliveCor
hardware. Using the semi-direct lead hypothesis of electro-
cardiography, we could use an “exploring electrode” on the
chest near the heart's surface and a distant “indifferent
electrode” on the lower left leg to record the unipolar chest
leads (V1, V2, V3, V4, V5, V6) [1]. In the absence of the
“Wilson central terminal,” we recorded the unipolar limb
leads (aVR, aVL, aVF) with an exploring electrode on the
focused limb and the other two limbs as the composite
indifferent electrode. This is the Goldberger unipolar limb
lead arrangement [3].
We show five examples of 12 lead ECGs recorded with
the use of a smart phone and the AliveCor technology. In its
present form, the AliveCor technology is different from the
Mac 5500 technology. The most obvious is the ease at which
the ECG is obtained on a 3-channel recorder and printed in a
standard 12 lead format. The AliveCor recorder is a single
channel, bipolar platform that we adapted to construct a 12
lead tracing. The AliveCor does not have a “Wilson central
terminal” which is a standard feature of the Mac 5500
recorder. This feature allows for effectively separating a
bipolar signal into two components and allows for the
unipolar recordings. The central terminal stabilizes the
electrical forces at the indifferent electrode by creating a
“zero potential”. This allows the unipolar exploring electrode
to accurately depict the focal electrical activity without the
interference of even a distant indifferent lead [1,2]. The
AliveCor presently does not have this feature. This probably
explains the differences in the magnitude of some of the
repolarization differences in the smart phone recordings.
These differences are magnified in the unipolar precordial
leads. This is seen in case #2 (simultaneous recordings)
where there is ST elevation in the precordial leads that is
absent in the Mac 5500 recording. Most differences in
repolarization (i.e. ST-T abnormalities) reflect the fact that in
cases #3, #4 and #5, the ECG recordings were done on
different days and the precordial leads are placed differently.
When it comes to depolarization (QRS morphology), the
accuracy of the smart phone recording appears to mimic the
standard tracings in all aspects. This is particularly so in the
two individuals (cases #1 and #2) where the recordings were
sequential using the same leads. In the other three individuals
the limb leads mimic the standard recordings but the chest
leads have some differences possibly due to differing chest
lead positions at the time of the two recordings on different
days. This series includes three individuals with abnormal
QRS complex morphology: LBBB, RBBB and dextrocardia.
All three are accurately depicted by the smart phone version
of the ECG. Depolarization is a shorter and less complex
 G.A. Baquero et al. / Journal of Electrocardiology 48 (2015) 1–7
electrical event than repolarization [1]. Despite the lack of a
“Wilson central terminal”, depolarization seems to be
accurately replicated by the smart phone. Repolarization is
prolonged and complex and it is easily influenced by any
change in positional, hemodynamic, metabolic and physio-
logical factors [1].
The populations that may find this “mobile 12 lead ECG”
useful might include those patients with a prior myocardial
infarction and those with documented arrhythmias. Patients
with known coronary disease may develop a clinical event
remote from a hospital but could record and transmit a 12
lead ECG. Those with known arrhythmias who develop
symptoms can record and transmit not just the single lead
event monitor strip but also a 12 lead recording of the
tachycardia for diagnostic review. The populations that may
benefit the most are in the third world where resources are
limited but a smart phone is available. A smart phone 12 lead
ECG in remote 3rd world locations could revolutionize the
recognition of acute cardiac issues in those without access to
healthcare in a more traditional setting.
Despite the obvious limitations of different precordial
electrode positions in some individuals, the study demon-
strates the feasibility of creating a 12 lead ECG with your
smart phone. A minor limitation is the time it takes to
construct the 12 lead recording on the smart phone. It takes
us about 10–12 minutes to obtain the 12 single channel
strips and place them into 12 PDF files. This time restraint
may be reduced by 50% after the learning curve has been
eliminated. The tracings are visualized on the smart phone's
screen separately. They can be transmitted as separate PDF
files for review on another device and then printed in
separate strips. The quality of the recordings would seem to
7
suggest that this technology could become an important
useful tool for clinical use. The series of 5 cases is small, but
each supports the concept that the smart phone technology
with its virtual 12 lead ECG can recreate a reliable QRS
complex. This does not validate the concept, but merely
presents it as plausible. Design of a new smart phone case
(hard ware upgrade) seems a small challenge. The APPs and
software upgrades to make the lead acquisitions simulta-
neous and easily transferable seem very plausible. The
addition of a “Wilson central terminal” is also plausible and
may help with stabilization of repolarization on the unipolar
recordings. This new hand held smart phone 12 lead ECG
recorder needs further development and validation.
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