LEFT PURKINJE Figers a Ce rr DO BO ee Si 0 ah)Electrocardiography Basics TARE BATES, HERE! Cour Ace ee 1 electrocardiogram is also known as an ECG; the Dutch and German version of the word, elektrokardiogram, is shortened to EKG. itis a tool used to visualize, or ‘gram’ the electricity, or “electro” that flows through the heart, or ‘cardio Specifically, a 12- lead ECG tracing shows how the depolarization wave, which is a wave of posite charge, moves during each heartbeat, by providing the perspectives of different sets of electrodes “This particular sel of electrodes 1s called lead Il, one electiode is placed on the right atm and tneother on the left leg. Essentially, when the waves moving toward the left leg electrode, you get postive deflection This big, positive deflection corresponds t the wave moving Gav the septum (Figure 1.1) Tounderstand the basics, let's start with an example of how we can look atthe heart with only oneparrof electrodes. a positive and a negative one (Figure 1.2; Figure 1.3) These electrodes detect the charge on the outside ofthe cell Remember, at rest, cells are negatively charged relate to the slightly positive outside environment, let's make these cells red (Figure 1.4) When they depolarze, the cells become positively charged, leaving a slightly negative charge in the outside environment, let's make these green (Figure 1.8). If we freeze this ‘wave of depolarization’ as it's moving through the cells, half the cells are negative, or depolarized, and half are positive and resting so there's @ ‘ference in charge across this set of cells (Figure 1.6). You can thinkof the charge difference as a dpole, because there are two electrical poles. We can draw this dipole out as an arrow, or vector pointing towards the positive charge (Figure 1.7) The electrodes detect charge on the outside of the cel so this points toward where the postive charge is, outside (Figure 1.8) Figure 14 el ELECTROCARDIOGRAM (ECG/EKG) eucctbiciTY Hener — vsunuite THING & KEEP 1s MIN oun se EOTe en [ee «RHYTHM, fbr me INTERVALS out Figure 12 Figure 13 OSMOSISORG 11Figure 14 CQ wm = == © GETS e Figure 16 Figure 112 Figure 113 12 OSMOSIS.ORGChapter 1 Electrocardiography Basics DEPOLARIZATION & DIPOLE VECTORS Now, if there's a dipole vector pointing toward the positive electrode, then the ECG tracing shows it a3 a positive deflection, the bigger the dipole. the bigger the deflection (Figure 1.9) If we unpause this, then everything becomes depolarized Since there's no diference in charge, there's no dipole, and thus no deflection (Figure 1.10) Moments later a wave of repolarization goes through and the cells become negative once again, Pausing halfway through again, now the dipole vector goes in the opposite crection and faces the negative electrode, this means that there wall be a negative ECG tracing (Figure 1.11) Again, the bigger the dipole ts, the bigger the negative deflection is Even though itd be nice if the depolanzation wave lined up perfectly with the electrodes, usualy that's not the case So, we simply lock at the vector component parallel to that electrode For example, let's say the depolanzation happened this way, at an angle, then, weld simply break the vector into two parts (Figure 1.12) The one we care about is gong towards the positive electrode, which causes a deflection, even though isa slightly smaller deflection than previously In other words the size ofthe deflection on the ECG tracing always corresponds to the magnitude, or size. of the dipole n the diection of the electrode. The perpendicular component ist pointing atthe electrodes, so it doesnt cause any deflection In fact there's a depolarization wave that goes straight up, perpendicular tothe positive and negative electrodes, there would be no deflection (Figure 1.12)! LIMB & CHEST LEADS In a standard ECG, there are 10 electrodes four limb electrodes, with one each on the left fim. ght arm, left le, and right leg, and six precordial electrodes, V, through V, that wrap round the chest The ght eg electrodes usualy used asa neutral lead, The heart isa three mensional organ, $0 V, through V, hne up i the transverse, or horizontal plane of the heart Each electiode is setup to detect any wave of posite charge coming towards it These are collectively called the chest leads (Figure 1.14) Figure 114 CORONAL PLANE 40-Lead ECG SVERSE Play CHEST LEADS. \ : OMe OSMOSIS. ORG 1314 OSMOSIS ORG Figure 145 ot |: MOSTLY ‘oe * Positive i Tt, | rt Gee ey, MOSTLY NEGATIVE Figure 146 T CIRCUMFLEX ARTERY LATERAL LeFT ANTERIOR DESCENDING ‘InerioR. canes ANTERIOR Riguy comonney percey Figure 197cr Nia on he night arm, and augmented vector let or aVL. on the left arm Both ofthese lease aerepresented a8 vectors that are 30 degrees up from the honzontal ine Augmented veces fot 2¥F 15.07 the lft foot, which anatomically isnt straight down, butts close enough that i ends up representing the vector facing straight down on the diagram. Just lke tre precoraiat electrodes, VA AV and aVF detect any posite deflection coming towards them fron. n addition to these three limb leads, there are also bipolar limb leads called lead I lesd {and ead I, which are recorded using two electrodes instead of just one Lead uses the Ra fg thenegatve pole and LA asthe postive pole, forming a vector that goes to the nght Lead gees aR as the negative pole and aVF as the posttwe pole, forming a vector that goes to the 160 earee mark Finally lead Il uses aVLas the negative pole and aVF asthe positive pole forming a vector that goes to the +120 degree mark So, n total you've got six leads fromm the imb leads and sox from the chest leads, which add up to 12 leads total. n other words. you have o 12:ead ECG. THE VALUE OF DIFFERENT VIEWPOINTS, tavng different views of the heart is important, because they make t possible for you to see how the wave of depolarization moves through the heart according to each viewpoint. For example, consider how the six chest leads, V, through V, register the depolarization ‘wave form called the QRS complex. The very same depolarization wave might appear mostly negative nV, and V,, isoelectric nV, and mostly positive in, V, and V,, because the exact rection and magnitude of the vectors are at different points in time Similarly, each of the frontal plane leads produces its own perspective of the depolarization wave (Figure 1.15). ‘The limb leads and chest leads can be grouped based on the regions of the heart that they are nearest, as we've indicated in this color-coded chart (Figure 1.16; Figure 1.17) Problems. in spectic leads, or groups of leads, suggests that there may be a specific region of the heart aflectedby a disease. Leads Ill and aVF are inferior’ leads because they're near the inferior wal ofthe heart, which receives blood from the Fight coronary artery Leads | and aV along with two ofthe chest leads, V, and V, are considered ‘lateral’ leads because they're near the lateral wall ofthe heart, which receves blood from the left circumflex artery Finally V, and V, are considered ‘septal’ leads because they're nearest to the interventricular septum. and V" and V, are ‘anterior leads because they're nearest the anterior wall ofthe heart. Both of the septal and anterior regions are served by the left antenior descending artery Figure 118, @ e—e@ “~ @-_ @ Ra e- eT OSMOSISORG 1516 OSMOSIS ORG SUMMARY Ath es qily recap na standard ECG there ae 10 eecttodes fou ib ¢ wrap around the chest. These electrodes are sede Mak and si precordial electrodes that aac ec of which iusrates the movement of positive charge onthe Outside of ep cells. The ECG tracing shows a depolat deflection, and one moving avvay 28 & the dipole The benefit of being abe to: to.see how the wave of depolarization mo heart's structure and function (Figure 1.18; mization wave moving towards an electrode as wegative deflection, each is propartonal tothe sat” soe diferent views ofthe heart is that it makes nace! ves, which provides valuable information sane Figure 1.19). the Figure 149 biNormal Sinus Rhythm osmosis.org/learn/normal_sinus_rhythm 10 1ead an ECG t's portant to fist understand what a normal sinus rhythm looks ke (Figure 2.1) To do that let's look ata single heartbeat on an ECG from the viewport of tead I DEPOLARIZATION Inabeathy heart everything starts atthe sioatnal node. r SA nade which site patch ‘of tyssue in the wall of the nght atrium full of pacemaker cells When one of these pacemaker cells depolanzes, a wave of positive charge spreads outward, overall, it moves from the SA rode towards the apex of the heart, sot aligns nicely with the lead 1! vector (Figure 2.2) gure 28 ELECTROCARDIOGRAM (€04/EKG) Loom eee ELECTRICITY HEART VISUALIZE ee : er oon SO / aime” NORMAL SINUS BAYTHAA ou Figure 22 RiGHT ATRIUM SINOATAIAL (5A) ae. PACEMARKER CELLS APEX OsMOSISORG 17Figure 23 unit post cabs commcins sow Premanst cas FASTER Figure 24 —_e oeuecrne Figure 25 Ssanove AV one THe poo: 3 awd | (en) mam oe Fens reRVAL PurKinye 18 OSMOSIS ORG— Chapter 2 Normal Sinus Rhythm ow the heart muscle cells are often described as having a functional syncytium because Neb though each one cel hast own cell membrane. he ess also have ty omer or crngs between them That means that dunng 2 depolarization wave is cor foe ight Fea INE Der. stan Goren ls eR ee two different speeds through the heart. In the pacemaker cell, which are special types of ‘cardiomyocytes laid out like highways through the heart, it moves really fast it moves more Sowly through the rest of myocytes that do the contracting, the depolarization wave moves, somigh these cel ke 3 car raveling tough small congested see Figure 2.3), READING DEPOLARIZATION ON AN ECG ‘The ECG measures out changes in time on the x 2:5 eerie EON and vottage on the Y-axis, with each small box equal hich 1s sometimes called 1 im voltage Zero 15 called the “isoelectric line” Every time there's positive voltage, there's an Upward deflection above the isoelectnc line, and every time theres negative vottage, there's ‘a downward deflection below the isoelectric line So, a depolarization wave starts in the SA nade, hen goes through atria! itranodel tracts, which is also called Bachmanns bundle. and travels over to the left atm so that both atria basically depolarze together The overall ddrection of that depolanzation wave is n the same direction as the lead Il vector, so that's considered positive voltage, and there's a positive deflection called the P wave (Figure 2.4) Meanwhile, the signal also gets carried from the SA)node to the atrioventricular node, or rode here. it gets delayed for abit. which allows the ara to fully contract and fil the ventricles vuth blood During ths delay, there is no depolarization wave moving towards of away from Jeodi,sothis appears asa flat line The interval from the beginning ofthe P wave through this, fiat portion is called the PRunterval From there, the signal goes through the pacemaker cells, thot make up the bundle of His and into the lft bundle branch and night bundle branches In addition to moving through the fast pacemaker cells, the signal also travels through the slow myocytes in the interventricular septum, ths direction is slightly away from the lead vector, because there i alot ofthis tissue This creates a tiny negative deflection on the ECG 2 Q wave (Figure 2.5) From there, the depolarization wave flows down into the Purkinje fibers. Since the largest vectors are the ones inthe left ventricle, this isin the direction of lead I, this creates a large positive deflection on the ECG aAwave. The apex of the heart depolarizes fict, but then the wave moves back up to depolarze the top ofthe ventricles, which sin a direction away from Jead Il, this causes a slight negative deflection on the ECG. an S wave. Together, ventricular depolarization creates what is called the ORS complex (Figure 2.6) Figure26 OSMOSISORG 1920 OSMOSIS ORG figue27 ce avpoxe sort LARGER Vectors, HYPERTROPHIC CARDIOYOPHEHY DAMAGED — sunset vectors HEART artnck Posttion »5 DiapHRaaia * OBESE —=YecToRS Moke LEFT TWN) —> VecoRs Moke BIGHT _ MEAN QRS VECTOR With this in mind, let's take a closer look at the mean, or average, QAS vector. After the ‘depolarization wave arrives at the AV node it travels down the interventricular septum and _ begins depolarizing the ventricles. The Purkinge fibers sit just below the endocardium, the ost layer of the heart. After the endocardium, there's the myocardium, the cardiac cells, and finally the epicardium, which is the outer layer. Therefore, each Purkinje fiber depolarization vector that travels directly outward it starts in the endocardium, goes 1 the myocardium, and ends in the epicardium (Figure 4,6) Because they transmit a ation wave so quickly, they all ire off pretty much in unison. The more muscle tissue layer that a vector has to travel through, the large the size ofthe vector So, Cardiomyopathy, where the heart muscle gets thicker, you get bigge? has been damaged, such as from a heart attack, then you the heart cells can't depolarize anymore. The position of the tors because i's usually sort of sitting night up against the iragm gets pushed upwards, rotating the heart further to the ffs, rotating the heart a bit the other way (Figure 4.7). OSMOSISORG 29ead & , sume 30 Osmosis ORG =e Figure 410 (cu anos) RIGHT Axis DewATION » Rion vewtece wrrchreepaies NorMac Axis vai Poin Hover ee a ate os ove ag Spain te Se en zee REM LEFT AXIS DeviATION RioHT ear “Tar vane ares hese an $B VOTEICLE DRMAGED © tndercr ugh “€aonic Fos oer ee eo ee — dose tases sueyOSMOSIS ORGFigure 414 Figure 415 Figure 416 Chest Leaps mostuy i Positive Ne sf \. v4 | Isoevectenc * TRANSITION 2oNE* vw ‘B Ve ve - Most Ne a al 32 OSMOSIS.ORGs Chapter 4 Axis ay oe wow CHEST Leaps roe pay Te abe ees verteauio” doy igo (ke hyparceny MC es, vive LY Preeentua erticrn vw (oevecreic HL Ragin ven bncul vs ‘* TRANSITION 2oNE = i ‘Swets Towne ce coutllion Si Geet sce ey eae everything is taken into consideration and all of the individual vectors are added up, RV ‘there's one overall representative vector arrow, which starts from the AV node and points in direction through the ventricles (Figure 4.8). Now, vectors can be broken down into two lat vector components, so if you look at the component pointing at the positive, (= Bee | ead electrode, that's what is recorded on the ECG. Therefore, when you plot these vectors over the course of ventricular depolarization, the QRS complex emerges (Figure 4.9) "All ight, to figure out the direction of the axis we can start by looking at leadifiand aVE Lead Yatost ect we Va V2, “imoyes from night to left across the heart, so anything pointing to the left wil be positive in in contrast, aVF points downward, so any vector pointing downward will be positive in F So, looking at our overall vector from before, t's pointing both down and to the left, and ‘ Thus, it's in the bottom left quadrant between 0 and +90 degrees, that's a If t's up in lead | and aVF, you can imagine it's like seeing two thumbs up, which ung is okay! If the vector is positive in lead | and negative in aVF. then it's it could be normal if it's between 0 and-30 degrees However, if i's between oricicy Lanet™ Suniel id be considered left axis deviation. Left axis deviation can happen when the extrophies, or when the night ventricle becomes damaged and loses healthy site happens, and the vector is negative in lead | and positive in aVF, then “S\ : \ +90 and +180 degrees, we call this night axis deviation. Right — naw fs en the right ventricle hypertrophies, or when the left ventricle is +Rapaguewee thee y tissue. Finally, ifthe vectors negative in both lead land VF, then (CCV owe treme right axis deviation between -90 and +180 degrees. This Jamis. nes. 's an ectopic focus that causes depolarization to start ‘and travel in the reverse direction. It's also a good idea to. >!2h~ wowtwlyhes laced correctly (Figure 4.10), Fconreanaicabens IN, aVR, AVL, and aVF which correspond 0,-20, and +90, respectively (Figure 4.11), Here, is somewhere over here, and lead aVF is it between 0 and +90 degtees, which is 00ks like lead Il 1s the closest to being c Hons; therefore, lead Ill must es subtract 90.degroes.is-the-+30 n the same line as aVR, but in the tor should look negative in aR, ~ OSMOSISORG 33