Electrocardiogram (ECG)

Electrocardiogram (ECG)
June 23 Electrocardiogram (ECG) 1

Normal ecg
• As cardiac impulses
passes thru the heart
• Electrical impulses are
spread from the heart to
the adjacent tissues
surrounding the heart
• And a small portion to
the surface of the body
• This electrical potential
generated by this
currents can be recorded

Normal electrocardiogram
• The recording is done by
placing
• electrodes on the skin on
opposite sides of the
heart
• Recording known as
electrocardiogram

Characteristics of a normal ecg
• Composed of
• P wave
• Caused by electrical potentials
generated when atria depolarize
before atria contraction begins
• QRS complex
• Three separate waves, the Q
wave, R wave and S wave

26-Jun-23 Physiology of the heart 5
• The QRS complex
• Caused by potential generated when the ventricles depolarize before contraction
• T wave
• Caused by potentials generated as a result of ventricular repolarization
• A 'U' wave which is the successor wave to the 'T' wave and may not always be observed as a result
of its minute (small) size. It represent re-polarization of the Purkinje fibers

• Thus electrocardiogram
is composed of
• Depolarization wave
• caused by spreading of
depolarization along the
cardiac muscle fibre
membrane

• Repolarization wave
• caused by spreading of
repolarization along the
cardiac muscle fibre
membrane

• There is also a depolarization wave in the atria (corresponding to P-
wave) and a repolarization wave of the atria.
• However, repolarization wave for the atria occurs at same time
depolarization of the ventricles is happening hence is obscured by the
much larger QRS complex.
• Occasionally, a U wave (a positive deflection occurring after the T-
Wave but much smaller than the T-Wave) is observed. It corresponds
to Purkinje fibers repolarization

Usefulness of ecg
• Analysis of the various waves and normal vectors of
depolarization and repolarization
• yields important diagnostic information.
• diagnosis of cardiac arrhythmias
• i.e disorders of rhythms
• Diagnosis of diseases of myocardium
• Cardiac hypertrophy
• It helps detect electrolyte disturbances
• e.g. hyperkalemia and hypokalemia

Usefulness of ecg
• It allows for the detection of conduction abnormalities
• e.g. right and left bundle branch block
• It is used as a screening tool for ischemic heart disease
• during a cardiac stress test
• It is occasionally helpful with non-cardiac diseases
• e.g. pulmonary embolism or hypothermia

Relationship of atrial & Ventricular
contraction to the waves of the ecg
• electrical events occurs in association with mechanical events
• Before contraction of a muscle can occur
• Depolarization must spread through the muscle
• to initiate the chemical processes of contraction
• P wave
• occurs at the beginning of contraction of atria
• QRS complex
• occurs at the beginning of contraction of ventricles
• The ventricles remain contracted until after repolarization has occurred
• i.e after the end of T wave

Relationship of atrial & Ventricular contraction to
the waves of the ecg
• Atrial repolarise about 0.15 to 0.20 s after termination of P wave
• At the same time QRS complex is being recorded in the ecg
• Therefore atrial T wave is obscured by much larger QRS complex
• Thus rarely observed in the ecg

Voltage and time calibration of the ecg
• All recordings on the ecg are made with appropriate calibration lines
on the recording paper
• Horizontal calibration lines
• Vertical calibration lines
• Horizontal calibration lines
• Represents the amplitude of the wave
• Positive
• Negative
• Vertical calibration lines
• Represents time interval

Normal voltages on the ecg
• When electrocardiograms are recorded

• The voltage of the QRS complex is usually 1.0 to 1.5 millivolts
• from the top of the R wave to the bottom of S wave
• The voltage of the P wave is between 0.1 and 0.3 millivolts
• And the T wave is between 0.2 and 0.3 millivolts

Normal time intervals of the ecg
• PQ or PR intervals
• Time between the
beginning of the P wave
and the beginning of QRS
wave
• Is the interval between
the beginning of
contraction of the atria
and the beginning of
contraction of the
ventricles

• Period normally called P-
R interval
• since Q wave is not
present all the time
• Duration interval 0.16
seconds

• Q-T interval
• Contraction of the
ventricle lasts almost
from the beginning of
the Q wave
• or R wave, if the Q wave is
absent
• to the end of the T wave
• Interval called the Q-T
interval
• Approx. 0.35 seconds

Rate of heart beat as determined from ecg
• Heart rate
• Is the reciprocal of the time interval between two successive heartbeats
• If time interval between 2 beats as determined in the calibration lines is 1
second, the HR is 60 beats per minutes
• The normal interval between two successive QRS complexes in the
adult person is about 0.83 second
• HR is 60/0.83 times per minute or 72 beats per minute

ECG Analysis
• Step 1:
• Is the Rhythm Regular or Irregular?
• If the intervals between QRS complexes (R-R intervals) are consistent,
ventricular rhythm is regular.
• If the intervals between the P waves (P-P intervals) are consistent,
atrial rhythm is regular.

Step 2:
• Are all the QRS complexes similar, and are they narrow?
• The duration of the QRS complex should not exceed 0.10 seconds (2
1/2squares).
• A widened complex indicates that ventricular depolarization is being
initiated by pacemaker tissue below the AV node e.g. ventricular paced
rhythm (one ventricle depolarizes first and the current must spread into
the other ventricle, taking more time than when both ventricles
depolarize simultaneously).

Step 3:
• Are All P waves similar and are PR intervals normal?
• If P waves are all similar and normal in shape, one can assume that the SA node is
the primary pacemaker.
• In this case, the rhythm is sinus in character.
• If the P waves vary in shape or are absent, other tissue (s) are functioning as
pacers.
• The PR interval is normally 0.12-0.20 seconds (3-5 small squares).
• Longer intervals indicate that the impulse is being delayed from entering the
ventricles and the condition is designated AV block.

Step 4:
• Do Waves and Complexes Proceed in Normal Sequence?
• Each P wave should be followed by a QRS complex, which is followed
by a T wave. This assures a normal sequence for each cardiac cycle.

Electrocardiograph Leads
• The ECG is taken using an active or exploring electrode connected to

an indifferent electrode at zero potential, this known as unipolar
recording
• Can also be done by using two active electrodes (bipolar recording).

• In a volume conductor, the sum of the potentials at the points of an
equilateral triangle with a current source in the center is zero at all
times.
• A triangle with the heart at its center (Einthoven's triangle) can be
approximated by placing electrodes on both arms and on the left
leg.
• These are the three standard limb leads used in
electrocardiography.
• If these electrodes are connected to a common terminal, an
indifferent electrode that stays near zero potential is obtained.
• Depolarization moving toward an active electrode in a volume
conductor produces a positive deflection, whereas depolarization
moving in the opposite direction produces a negative deflection.

The Einthoven’s Triangle

Three bipolar leads
• When recording lead I, the -ve terminal of the ECG is connected

to the right arm and the +ve terminal to the left arm.
• Therefore, when the point where the right arm connects to the
chest is electro-ve with respect to the point where the left arm
connects, the ECG records +vely, that is, above the zero voltage
line in the ECG.
• When the opposite is true, the ECG records -vely.

Lead II
• -ve terminal of ECG is connected to the right arm and the +ve
terminal to the left leg.
• Therefore, when the right arm is –ve with respect to the left leg, the
ECG records +vely.

Lead III
• Here, the –ve terminal of the ECG is connected to the left arm and the
+ve terminal to the left leg.
• This means that the ECG records positively when the left arm is
negative with respect to the left leg

• The Einthoven's Triangle is a triangle drawn around the area of
the heart.
• Illustrates that the two arms and the left leg form pieces of a
triangle surrounding the heart.
• The two pieces at the upper part of the triangle represent the
points at which the two arms connect electrically with the fluids
around the heart, and the lower apex is the point at which the
left leg connects with the fluids

The Einthoven's Law
• It states that if the electrical potentials of any two of the three bipolar
limb ECG leads are known at any given instant, the third one can be
determined mathematically by simply summing the first two.
• The ECG’s of all 3 bipolar leads are similar to one another.
• All record positive P and T waves with major portion of the QRS
complex positive.
• The sum of potentials in lead I and lead III is equal to potential of
lead II

• This is an example of a
recording of the bipolar leads. If
you total the voltages in lead I &
III, the total will be the voltages
in lead II

Chest Leads (Precordial Leads)
• The ECG’s are recorded with one electrode on the anterior chest
surface directly over the heart and connected to the +ve terminal
of the ECG.
• -ve terminal (called the indifferent electrode) is connected to the right
arm, left arm, and left leg all at the same time.
• Usually, six standard chest leads are recorded, each at a time, from
the anterior chest wall, the chest electrode being placed sequentially
at the six points shown in the diagram.

• These different recordings are known as leads V1, V2, V3, V4, V5,
and V6.
• Each of the leads records the electrical potential of the cardiac
musculature immediately beneath the electrode.
• As such, relatively minute abnormalities in the ventricles,
particularly in the anterior ventricular wall, can cause marked
changes in the ECG’s recorded from individual chest leads.

• In leads V1 and V2, the QRS recordings of the normal heart are mainly
negative.
• This is because the electrodes in these leads are nearer to the base of
the heart than to the apex, and the base of the heart is the direction
of electronegativity during most of the ventricular depolarization
process.

• The QRS complexes in lead V4, V5, and V6 are mainly positive since
the electrodes here are at the apex of the heart which is the direction
of electropositivity during most of depolarization.

Augmented Unipolar Limb Leads
• Here, two of the limbs are to the negative terminal of the

electrocardiograph, and the third limb is connected to the positive
terminal.
• When the positive terminal is on the right arm, the lead is known as
the aVR lead; when on the left arm, the aVL lead; and when on the
left leg, the aVF lead.
• The readings are all similar to the standard limb lead recordings,
except that the recording from the aVR lead is inverted.

• In the normal human heart, each beat originates in the SA node (normal
sinus rhythm, NSR).
• The heart beats about 70 times a minute at rest. The rate is slowed
(bradycardia) during sleep and accelerated (tachycardia) by emotion,
exercise, fever, and many other stimuli.
• In healthy young individuals breathing at a normal rate, the heart rate
varies with the phases of respiration: It accelerates during inspiration and
decelerates during expiration, especially if the depth of breathing is
increased.

• The sinus arrhythmia is a normal occurrence and is due to
fluctuations in sympathetic and parasympathetic output to the
heart during normal daily activities.
• In inspiration vagal impulses from the lung stretch receptors
inhibit the cardio-inhibitory area in the medulla oblongata.
• This inhibitory of the leads to increase in heart rate.
• When we are active, there is increased sympathetic discharge
which causes increase in heart rate.

• The conduction between the atria and ventricles may be slowed
without complete interruption.
• In this case, there is incomplete heart block.
• In first-degree heart block, all the SAN impulses reach the ventricles
but the PR intervals become prolonged.
• In second-degree heart block, some of SAN impulses are not
conducted to the ventricles. A ventricular beat may follow every 2nd
or 3rd third atrial beat (2:1 block, 3:1 block, etc).

• In another form of incomplete heart block, there are repeated
sequences of beats in which the PR interval lengthens progressively
until a ventricular beat is dropped (Wenckebach phenomenon).
• The PR interval of the cardiac cycle that follows each dropped beat is
usually normal or only slightly prolonged.

• At times, a branch of the bundle of His may be interrupted.
• May cause right or left bundle branch block.
• In bundle branch block, impulse passes normally down the
bundle on the intact side and then sweeps back through the
muscle to activate the ventricle on the blocked side.
• The ventricular rate will be normal but the QRS complexes will be
prolonged and deformed.

• Normally, myocardial cells do not discharge spontaneously, and the
possibility of spontaneous discharge of the His bundle and Purkinje system
is low because the normal pacemaker discharge of the SA node is more
rapid than their rate of spontaneous discharge.
• However, in abnormal conditions,
• i. The bundle of His, Purkinje fibers or the myocardial fibers may discharge
spontaneously and so become the cardiac pacemaker.
• ii. Diseased atrial and ventricular muscle fibers can have their membrane
potentials reduced and discharge repetitively.
• If the focus discharges repetitively at a rate higher than that of the SA
node, it produces rapid, regular tachycardia (atrial, ventricular, or nodal
paroxysmal tachycardia or atrial flutter).

Premature beats
• Premature beats, are heart beats that originate in the atria or the
ventricles, they are the most common causes of cardiac arrhythmia.
• They occur in individuals with normal hearts as well as in patients
with heart disease of lesser or greater severity.

Cardiac arrhythmias
• Are disturbances in the rhythm of the heart, manifested by
irregularity or by abnormally fast rates (tachycardias) or abnormally
slow rates (bradycardias).
• It is characterized by palpitations, weakness, shortness of breath,
lightheadedness, dizziness, fainting (syncope) and occasionally, chest
pain.

Definitions
• Paroxysmal means that the episode of arrhythmia begins and
ends abruptly.
• Atrial means that arrhythmia starts in the atria or upper
chambers of your heart.
• Tachycardia means that the heart is beating abnormally fast.
• Paroxysmal atrial tachycardia (PAT) is also known as paroxysmal
supraventricular tachycardia (P.S.V.T)..

• A tachyarrhythmia that is rapid enough and lasts long enough can
produce cardiomyopathy and congestive heart failure.
• The name bigeminy is applied to those premature beats that
alternate with sinus beats, trigeminy when one or two of three beats
are premature, and quadrigeminy when one of four beats is
premature

• Atrial premature beats are produced by abnormalities of atrial
electrical activity that discharge the atria early in competition with
the normal function of the sinus node.
• The form or morphology of the P waves of atrial premature beats is
abnormal, reflecting their origin other than sinus node
• Atrial premature beats may indicate the presence of atrial pathology,
which can produce sustained atrial arrhythmias such as atrial
fibrillation or atrial flutter.

• Ventricular premature beats are recognized by the presence on the
electrocardiogram of early QRS complexes with abnormal forms
indicating their origin in the ventricles.
• They occur in every patient during myocardial infarction and more
frequently in those who have sustained greater amounts of
myocardial damage.

• Patients with angina pectoris have more ventricular premature beats and both
simple and complex beats frequently develop during episodes of coronary
vasospasm.
• Other causes include cardiomyopathy, hypertension, pulmonary disease,
congenital heart disease, cardiac surgery, metabolic disturbances, alcohol and
certain drugs, the time of day, whether one is awake or asleep.
• Stress affects the frequency of ventricular premature beats.
• On the ECG,the form of the QRS complexes of the ventricular premature beats
is abnormal. Their duration is prolonged, and their amplitude is frequently
greater.

Abnormal pacemaker
• When conduction from the atria to the ventricles is completely

interrupted it is referred to as complete (third-degree) heart block,
and the ventricles beat at a low rate (idio-ventricular rhythm)
independently of the atria.
• The block may be due to disease in the AV node (AV nodal block) or in
the conducting system below the node (infra-nodal block

• In AV nodal block, remaining nodal tissue becomes the pacemaker and the rate of
idio-ventricular rhythm is 45/min.
• In infra-nodal block due to disease in the bundle of His, the ventricular
pacemaker is located more peripherally in the conduction system and the
ventricular rate is lower; it averages 35 beats /min, but can go to 15 beats/min. In
such individuals, there may also be periods of asystole lasting a minute or more.
The resultant cerebral ischemia causes dizziness and fainting (Stokes-Adams
syndrome). Causes of third-degree heart block include septal myocardial
infarction and damage to the bundle of His during surgical correction of
congenital interventricular septal defects.

Reentry
• A more common cause of paroxysmal arrhythmias is a defect in conduction that

permits a wave of excitation to propagate continuously within a closed circuit
(circus movement). For example, if there is a transient block on one side of a
portion of the conducting system, the impulse can go down the other side.
• If the block then wears off, the impulse may conduct in a retrograde direction in
the previously blocked side back to the origin and then descend again,
establishing a circus movement. If the reentry is in the AV node, the reentrant
activity depolarizes the atrium, and the resulting atrial beat is called an echo
beat.

Inherent rates
• SA 60-100
• AV JUNCTION 40-60
• VENTRICULAR 20-40

SINUS DYSRHYTHMIA
• Occurs if the P-R interval vary by more than 0.16 . less than 0.16 is
considered normal because of the fluctuation of the sympathetic/
parasympathetic stimulation
• Associated with respiration in children and elderly

SINUS BRADYCARDIA
• Hr < 60/min arising from the SA node.
• Impulses follow the normal pathway through the conduction system
• P and QRS complexes normal duration and pattern

SINUS TACHYCARDIA
• HR of 100-160/ min
• Normal response to sympathetic nervous system stimulation
• Any condition that produces an increase in metabolic rate

• ECG with a normal upright P wave preceding every QRS complex,
indicating that the pacemaker is coming from the sinus node and not
elsewhere in the atria
• P wave conducts through the AV node to Ventricles to produce a QRS
complex in a 1:1 fashion
• On occasion, sinus rate can be different from the ventricular rate ―
known as AV dissociation ― such as in ventricular
tachycardia or third-degree AV block.

ATRIAL DYSRHYTHMIA
• Impulse arises outside the sino atrial node
• P waves differ in configuration
• Types
• Wandering atrial pacemaker
• Premature atrial contractions
• Paroxysmal atrial tachycardia
• Atrial flutter
• Atrial fibrillation

Premature Atrial Contractions
• Most common ectopic beat

• Occurs when impulse is generated by an irritable area of tissue in the
atria
• Abnormally shaped P wave
• QRS complex not affected

Paroxysmal atrial tachycardia
• Caused by an irritable area of tissue in the atria that dominates the
sinoatrial node and takes over as the pacemaker
• Usually preceded by premature atrial contractions
• Begin and end abruptly
• The raid rate prevents adequate ventricular filling

ATRIAL FLUTTER
• Atrial ectopic pacer fires at a rate of 250-400/ min
• Occurs in a variety of heart diseases- rheumatic, coronary,
hypertensive, also cardiomyopathy-(disease of the heart muscle that
makes it harder for the heart to pump blood to the rest of the body),
hypoxia, heart failure
• May be asymptomatic or have palpitations
• Management- digitalis, beta blockers, calcium channel blockers

Atrial Flutter

Atrial Fibrillation
• Several ectopic foci causing the atria to quiver rather than contract.
• Rate >400
• Ventricular rate depends on the number of impulses conducted thru
the AV node
• Management- dig., Beta blockers, calcium channel blockers,
countershock

Atrial Fibrillation
• Rhythm Irregular
• Rate: Very fast for Atrial, but ventricular rate may be slow, normal or
fast
• P Wave: Absent - erratic waves are present
• PR Interval: Absent
• QRS: Normal but may be widened if there are conduction delays

AV Heart blocks:
• Abnormal delay in conduction of impulse from the atrium to the
ventricles
• Usually asymptomatic
• Delay occurs at the AV node producing a prolonged PR interval >
0.20s

• Common occurrence in normal hearts
• Cardiac disease including:
–Arteriosclerotic heart disease, myocarditis, myocardial infarction
• Medications:
–Beta blockers
–Calcium channel blockers
–Digitalis toxicity

2nd Degree Heart Block
• Progressive lengthening of the PR interval until a QRS Complex is
dropped or not conducted
• Usually asymptomatic
• Treatment: MAYBE NONE, ATROPINE, TEMP. PACER

SECOND DEGREE- TYPE II
• Every 2nd, 3rd or 4th sinus impulse is blocked may have 2,3,4 P’s to each
QRS
• More serious- aggressive management to prevent progression to
complete heart block
• Treatment:
– pacer maker
–Atropine
–Dopamine for severe hypotension

3rd Degree Heart Block
• Total disassociation of atria to ventricles. Ventricles are stimulated by a
secondary or escape beat.
• Ventricular rate will be less than 45 -50 beats per minute depending upon
the location of the ventricular pacemaker
• Both the sinus P wave and the escape rhythm will be obvious on the
electrocardiogram
• Etiology –
–Cardiac disease
–Medications – beta blockers, calcium channel blockers, digitalis toxicity
• Manifestations- fatigue, hypotension, syncope, heart failure
• Tx.- Atropine, isoproterenol, dopamine
JUNCTIONAL RHYTHMS
• Rate 40- 60
• The dominant pacer of the heart fails , retrograde or backward stimulation of the
atria- producing a characteristic P wave - may be a negative deflection before or
after the QRS complex or no P wave at all
CAUSES:
• Coronary artery disease, Congestive heart failure
• Myocardial infarction
• Caffeine, Anxiety, Alcohol, tobacco

Symptoms and Management
• Feelings of
• Palpitations
• Fluttering
• “Skipped beats”
• Tx underlying cause
• Modify diet / lifestyle
• Reduce stress
• Medications :Quinidine

Junctional Escape Beats
• Beats that occur when the AV junction takes over the pacemaker
activity
• Occur late in the cycle
• Rheumatic heart disease
• Myocardial infarction
• Sinus arrhythmias:
• Bradycardia
• Block
• Arrest

Ventricular dysrhythmias
• Impulse originates in the ventricles
• Causes- drug toxicity, hypoxia, hypothermia, electrolyte imbalances

Premature ventricular contractions
• Occur early- noted compensatory pause, QRS complex wide
• May be multifocal or unifocal

Ventricular Tachycardia
• Defined as three or more premature ventricular contractions in a row
• Rate of ventricular discharge is 100-250/min
• Etiology- increased myocardial irritability associated with coronary
artery disease, myocardial infarction, electrolyte imbalance,
cardiomyopathy

VENTRICULAR FIBRILLATION
• Rapid, disorganized ventricular rhythm that results in ineffective
quivering of the ventricles
• No atrial activity seen on ecg
• Absence of audible heartbeat, palpable pulse, and respiration

Causes
• Same as ventricular tachycardia
• Untreated ventricular tachycardia
• Electrical shock

• Immediate defibrillation
• Activation of emergency medical service
• Cardiopulmonary rescucitation
• Eradicating the cause
• Vasoactive and antiarrhythmic medications


Electrocardiogram (ECG)

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Electrocardiogram (ECG)

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Electrocardiogram (ECG)

June 23 Electrocardiogram (ECG) 1

June 23 Electrocardiogram (ECG) 2

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• When electrocardiograms are recorded

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• The ECG is taken using an active or exploring electrode connected to

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• When recording lead I, the -ve terminal of the ECG is connected

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• Here, two of the limbs are to the negative terminal of the

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• When conduction from the atria to the ventricles is completely

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• A more common cause of paroxysmal arrhythmias is a defect in conduction that

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