Electrocardiography (

Electrocardiogram
ECG / EKG)
An electrocardiogram records the electrical signals in your heart. It's a common and painless test used to quickly detect
heart problems and monitor your heart's health. Electrocardiograms — also called ECGs or EKGs — are often done in a
doctor's office, a clinic or a hospital room.
➢ Electrocardiography is the process or method of graphic tracing of the electric current generated by the
heart muscle during a heartbeat.
➢ It is a process of recording the current generated by the heart muscle during a heartbeat – ECG
➢ The device that records the electrical signal of the heart is ELECTROCARDIOGRAM (machine/device).
➢ Anything related to the heart or the status of the heart can be recorded by the electrocardiogram.
➢ ECG is the procedure or process
➢ Electrocardiogram is the machine or device that records the amount of current produce in a person’s
heart during functioning
➢ Standard equipment in the operating room and ambulances.

…ITS HISTORY
• The precursor of ECG is Dr. Luigi Galvani. He is an Italian physician at the University of Bologna that first noted
the electrical current could be recorded from the skeletal muscle.
• Recorded electrical activity from a dissected muscle
• In 1842, Dr.Carlo Matteuci demonstrated the electrical activity from the heart of a frog.
• 35 years later, Augustus Waller, a British physiologist of St.Mary’s Medical School in London published the first
human electrocardiogram using a capillary electrometer and electrodes placed on the chest and back of a human.
• Augustus Waller used 5 electrodes to record the human heart activity.
• Then in 1893, Dr. Willem Einthoven refined the capillary electrometer and even further was able to demonstrate
these 5 deflections which he named PQRST
• used for the first time, the termed EKG
• The term electrocardiogram is used to describe these waveforms on PQRST.
• It was first coined by Dr. Einthoven.
• Dr. Einthoven invented the 3 lead EKG machine.
• Because of Einthoven’s discovery or invention, he won a Nobel Prize Award.
• This is where the ECG machine started.
• Then eventually, there are also modification, enhancements of the ECG machine then until now, it is used.
• Today we use a 12-lead EKG machine in the clinic and hospital.
• Certain inventions that may have similarities to ECG principle like the smartwatches in which it records the heart
activity and also, sleep rate, breath rate.

Electrocardiogram | Ortega, Julianne

TYPES OF ECG
1. Resting ECG Training
• standard test for measuring heart’s electrical
function
• records your heart’s electrical activity from 12
electrodes (sticky patches) on your chest, arms,
and legs at the same time.
o We perform it while lying still.
o This Resting ECG Training is part of the
routine check up
o We used that for heart condition
screening before any signs or symptoms
develop.
o Annual check up, 40 years old above,
routine test (resting ECG is included)
2. Exercise/Stress ECG Training
• Also known as stress test, treadmill test or
exercise EKG
• The patient walks on a treadmill or pedals a
stationary bicycle.
• Breathing and blood pressure rates are also
monitored.
• This is used to detect coronary artery disease,
and/or to determine safe levels of exercise
following a heart attack or heart surgery.
o For example: patient already has heart
condition but still advised regarding
healthy living, exercise ○ This procedure
can determine what are the allowable
stress or exercise/movement that is safe
for patient
o It is given while the patient walks on a
treadmill or a pedal bike/stationary bike
during stress/exercise while the patient
is moving.
o At the same time, blood pressure rates
are being monitored on this type of ECG
testing.
3. Holter Monitor
• a type of electrocardiogram (ECG or EKG) used
to monitor the ECG tracing continuously for a
period of 24 hours or Longer
EXAMINATION PROTOCOL
Pre-Examination
1. Remove any jewelry or other objects that may
interfere with the test.
2. Depending on the reason for your ECG, your
doctor may ask you to stop taking some of your
medications.
o Most important factor in pre-examination
phase is making sure that the patient is
relaxed (Informed and comfortable
position)
o The patient should be in a lying position,
lying comfortably on a bed, stress chair
or table that is wide enough to support
his arms and legs.
o Remove metal objects, shoes
o Make sure that the patient ay hindi
nilalamig or can’t feel coldness because
it is possible to remove the top clothing.
Examination
1. Remove clothing from the waist up.
2. Lie flat on a table or bed for the test.
3. If your chest, arms, or legs are very hairy, the
technician may shave or clip small patches of
hair, as needed, so that the electrodes will stick
closely to the skin.
Electrocardiogram | Ortega, Julianne
 o Sometimes, electrodes do not stick to o The green electrode is placed at the left
the specific part so that it needs to be leg.
shaved. o There are certain manufacturers that
o Oily skin, put alcohol/alcohol swab, may define different electrodes in
allow to air dry before putting the different colors. Follow the
electrode. manufacturer’s instructions but that is
4. Electrodes will be attached to your chest, arms, the common (referring to previous 3
and legs. lead placement) ○ The first
5. Once the leads are attached, the technician may procedure/way of ECG setup is on the
enter identifying information about you into the part of the left part of abdomen, pectoral
machine's computer. muscle.
6. The ECG will be started. It will take only a short o Another way for ECG setup using
time for the tracing to be completed. Eindhoven’s triangle, left leg.
7. Once the tracing is completed, the technician
will disconnect the leads and remove the skin
electrodes.
o Before entering the patient information
in the machine, allows the electrolyte
materials to interact with the skin.
o Double check if the electrodes are
properly attached.
ECG Setup
1. CARDIAC MONITORING – ECD Lead
Placement

WHAT IS THE DIFFERENCE BETWEEN THE LEADS

AND ELECTRODES?
o Electrodes are the ones that transmit
electrical impulses given off by the heart
to the machine through lead wires. The
back of the electrodes contains
electrolyte gel which helps in
conduction.
o Leads are strategically placed in the
body to pick up the impulses throughout
the body. This tells us if the electrical
current is traveling throughout the body.

ECG Leads
• Bipolar Limb Leads
o register the voltage between two
electrodes
❖ Lead I: (-) right arm and left arm (+)
RA RED Electrode placed under right clavicle near
right shoulder within the rib cage frame. o the most sensitive to electrical activity
LA YELLOW Electrode placed under left clavicle near left that spreads horizontally across the
shoulder within the rib cage frame.
LL GREEN Electrode placed on the left side below heart
pectoral muscles lower edge of left rib cage
❖ Lead II: (-) right arm and left leg (+)
2. EINDHOVEN’s TRIANGLE o the most sensitive to electrical activity
o The second procedure or way of placing that spreads vertically across the heart
the electrodes is the Eindhoven’s o Direction: base to apex
triangle. ❖ Lead III: (-) left arm and left leg (+)
o The red electrode is placed at the right o Also records electrical activity spreading
arm from the base to the apex of the heart
o The yellow electrode is placed at the left o Direction: base to apex, but in a different
arm orientation

Electrocardiogram | Ortega, Julianne

 o Bipolar means it can be recorded
between two electrodes.
o The lead 1 records the current right arm
and left arm
o The lead 2 records the electric current
from the right arm and left leg.
o While the lead 3, records the electrical
current from the left arm and left leg.
o The leads can be bipolar or unipolar.
• Unipolar Limb Leads
o register activity in the heart which is
directed towards, or located below the
electrode.
o The ECG machine usually augments the
potential by 1.5 than original potential
Comes from a central terminal
❖ Lead I: (-) right arm and left arm (+)
❖ Lead II: (-) right arm and left leg (+)
❖ Lead III: (-) left arm and left leg (+)
o This electrode is also called the
Wilson electrode.
Unipolar Limb Leads
aVR (Augmented Vector Right)
• Orientation: aVR is situated to look at
the heart's activity from the right
shoulder towards the midpoint between
the left shoulder and the left leg.
• Polarity: It is oriented towards the right
arm and the ECG voltage recorded is
negative.
• Clinical Use: aVR is often used to detect
myocardial ischemia or infarction
involving the right coronary artery (RCA)
territory. In normal conditions, aVR
typically shows negative deflections as
it often reflects opposite electrical
activity compared to the other leads.
aVL (Augmented Vector Left)
• Orientation: aVL is positioned to
examine the heart's electrical activity
from the left shoulder towards the
midpoint between the right shoulder and
the right leg.
• Polarity: It is oriented towards the left
arm and the ECG voltage recorded is
positive.
• Clinical Use: aVL can be useful in
detecting myocardial ischemia or
infarction involving the circumflex artery
territory. It's also valuable in assessing
electrical axis deviation and left
ventricular hypertrophy.
aVF (Augmented Vector Foot)
• Orientation: aVF looks at the heart's
electrical activity from the midpoint
between both shoulders towards the
feet.
• Polarity: It is oriented towards the feet
and the ECG voltage recorded is
positive.
• Clinical Use: aVF helps in assessing
myocardial ischemia or infarction
involving the inferior wall of the left
ventricle. It's also important in
determining the electrical axis of the
heart.
Chest Leads
• six electrocardiogram (ECG) leads that are
placed on the chest to record electrical activity of
the heart from different perspectives. These
leads are labeled V1 through V6. Unlike the limb
leads, which monitor electrical activity along the
frontal plane (from different positions on the
limbs), chest leads provide a view of the heart's
electrical activity in the horizontal plane, looking
at the heart from the front of the chest.
o The chest lead has 6 electrodes namely
V1,V2,V3,V4,V5, AND V6. So these
leads are labeled as V leads and
numbered V 1-6. There are position
specific forms on the rib cage 5
o To position them accurately, it is
important to be able to identify the Angle
of Louis/Sternal angle/Sternum angle
o To find the Angle of Louis , place your
fingers - two fingers at the base of the
throat then move carefully downward to
feel the bony lump. The bony lump is
called the Angle of Louis.
o This is a sample of 12 Lead ECG
o Used 10 electrodes that will be attached
to the patients
o The 6 chest leads: V1,V2,V3,V4,V5,V6
either the unipolar or bipolar leads
placed in the right arm, left arm, left leg,
and right leg.
o If 3 leads ECG is used you can only
place it on the right arm, left arm and left
leg.
o The electrodes detect electrical activity.
THE POSITIVE ELECTRODE VIEW OF THE
LEAD PLACEMENT HEART
V1 4th intercostal (ICS) to the Septum
right of the sternum
(parasternal line (PSL)
V2 4th intercostal (ICS) to the left
of the sternum (parasternal
line (PSL)
V3 Directly between V2 and V4 Anterior
V4 5th ICS at left MCL
V5 Level with V4 at left AAL Lateral
V6 Level with V6 at left
midaxillary line
LEAD POSITIVE ELECTRODE PLACEMENT VIEW OF
THE HEART
V1 and V2: These leads are generally considered to be
"negative" because they record electrical activity
directed away from the positive electrode. V3 to V6:
These leads are typically considered "positive" because
they record electrical activity directed towards the
positive electrode.
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NOTE: 10 electrodes only - AVR and AVL are
augmented leads, not electrodes. That’s why in a
standard 12-Lead ECG, only 10 electrodes are used
❖ aVR = -1/2(LA + LL), where LA and LL
represent the electrical potentials recorded by
the left arm and left leg electrodes, respectively.
❖ aVL = -1/2(RA + LL), where RA and LL
represent the electrical potentials recorded by
the right arm and left leg electrodes,
respectively.
Purpose of ECG
• Detects your heart's electrical rhythm and
produces what's known as tracing.
• This tracing consists of representations of
several waves that recur with each heartbeat.
• The wave pattern should have a consistent
shape. If your waves are not consistent, or if
they do not appear as standard waves, this is
indicative of heart disease.
o ECG is used to check the heart status or check
the health of the heart.
o Very important in diagnosis of cardiovascular
diseases like arrhythmia or Abnormal heart
rhythm, Myocardial ischemia/infarction,
Chamber enlargement (hypertrophy), Electrolyte
abnormalities.
Important diagnostic tool in the evaluation of CVD
• Abnormal heart rhythm (arrhythmias)
• Myocardial ischemia/infarction
• Chamber enlargement
• Electrolyte abnormalities
Post Examination
• You should be able to go back to your normal
diet and activities unless your doctor tells you
differently.
• Generally, there is no special care after an
electrocardiogram (ECG).
• Tell your doctor if you develop any signs or
symptoms you had before the ECG
• (for example, chest pain, shortness of
breath, dizziness, or fainting)
o You should get your results so
that you can know if there are
any modifications to your diet.
When reading the ECG, look at the
1. Name
2. Age
3. Date
4. Standardization
CARDIAC CYCLE
Cardiac Cycle: is the sequence of events (electrical and
mechanical events taking place in the heart from the
beginning of one heartbeat initiated by an impulse from
the SA node.
Depolarization is the wave of electrical activity that
spreads through the heart muscle cells, initiating the
contraction of the heart chambers (atria and ventricles)
Repolarization occurs when the electrical potential
inside the cell becomes negative again relative to the
outside, restoring the cell to its resting state.
• Electrical events: depolarization of the atria
and depolarization and repolarization of the
ventricle
• Mechanical events: contraction or relaxation of
the atria and ventricles
CONDUCTION SYSTEM OF THE HEART
Electrocardiogram | Ortega, Julianne
Sinoatrial (SA) Node: The electrical impulse originates ▪ First concept, conduction system of the heart
in the SA node, located in the right atrium. When the SA came from the cardiac cells that are responsible
node fires, it triggers depolarization of the atrial muscle in conducting signals that cause the heart to
cells, leading to atrial contraction. This contraction contract.
pushes blood from the atria into the ventricles. ▪ First cell is called SA (sinoatrial) node (first
• On the ECG: the depolarization of the yellow dot - upper left), this cell is found within
atria is represented by the P wave. the right atrium of the heart. Known as the
natural pacemaker of the heart because this is
Atrioventricular (AV) Node: After the atria contract, the where the beginning of the conduction takes
electrical impulse travels to the AV node, located place.
between the atria and the ventricles. The AV node ▪ From the SA node, the conduction goes from AV
delays the impulse briefly to allow the ventricles to fill node, this can be found within the border of the
completely with blood from the atria before transmitting right atrium and right ventricle. This AV node is
the impulse to the ventricles. known as the gatekeeper of the heart. AV node
• The delay in the AV node is not directly is the one that decides if the conduction will go
visible on the ECG but contributes to the through or not.
PR interval, which reflects the time from ▪ If the SA node generates a weak impulse, AV
atrial depolarization (P wave) to node is the one that decides if it lets through the
ventricular depolarization (QRS weak impulse.
complex) ▪ From the AV node,it goes to the single structure
that is the Bundle of His. From the Bundle of
Bundle of His, Bundle Branches, and Purkinje His, the cells will continue and separate into two
Fibers: Once the impulse passes through the AV node, cells.
it travels rapidly down the bundle of His, bundle ▪ Left and Right bundle branches
branches, and Purkinje fibers, which are specialized ▪ From the bundle of branches, they will extend to
conducting pathways that distribute the impulse the apex of the heart and that will be called the
throughout the ventricles. This rapid transmission of the Purkinje fibers.
electrical impulse causes depolarization of the ▪ SA node to AV node, Bundle of HIS, R/L bundle
ventricular muscle cells, leading to ventricular branches and Purkinje fibers.
contraction.
• On the ECG, ventricular depolarization In Summary:
is represented by the QRS complex, PART DESCRIPTION BPM REPRESENTED
BY
which consists of the Q wave, R wave, SA Node Primary 60-100 P wave
and S wave. pacemaker BPM
AV Node Backup 40-60 BPM PR Interval
pacemaker
Bundle of Point where - QRS complex
His impulses divide
Bundle Sends impulses -
Branches to the left and
right sides of the
heart
Purkinje Nerves branching 30-40 BMP
Fibers to the ventricles.
backup or when
both SA and AV
Nodes Fall

Components of an ECG Waveform

Ventricular Repolarization: After contraction, the
ventricular muscle cells undergo repolarization,
preparing them for the next heartbeat. ECG rhythm strip
• an actual reading of the heart activity
Wherever the electrical impulse travels in the heart's represented by a series of waveforms -
conduction system, it causes specific parts of the heart
to contract, ensuring that the atria and ventricles contract
in a coordinated sequence to efficiently pump blood
throughout the body.

Electrocardiogram | Ortega, Julianne

Waveforms

2. Identify the PR Interval

• Normal PR interval: 0.12-0.20 seconds
• Note:
1. P-Wave o 1 small square=0.04 second
o 1 big square=0.2 second
• Atrial contraction (depolarization)
3. Evaluate the QRS Complex
• Think “Prepare and pump”
• Check whether every P-wave is followed by a
▪ Present QRS Complex
▪ Positioned upright • Should NOT be widened or shortened - this may
▪ Prior to QRS Complex indicate problems
▪ Paired to a QRS Complex • Normal QRS complex: 0.06-0.12 seconds
4. Identify R-R Intervals
2. PR-Segment • Check whether they are consistent
• Movement of electrical activity from the atrium to • Check whether they are regular or irregular
the ventricles
• Flat segment representing the travel portion of
electrical activity from atrium to the ventricles
3. QRS-Complex
• Ventricular contraction (depolarization)
4. QT-Interval
• Time that it takes for the ventricle to contract 5. Check for the heart rate
and relax • Applicable if the ECG strip is a 6-second strip
5. ST-Segment
• Important to look out for as ST-segment
elevation can indicate myocardial infarction,
ischemia, or other injuries to the heart
• The time between depolarization (pumping) and
repolarization (filling of blood)
6. T-Wave
• Repolarization 6 Second Method Big Box Method
• “Relaxing and Refilling of Blood” - preparation of Heart Rate = no of R x 10 Heart Rate = 300 /
its next beat Number of Big Boxes in
between Rs
INTERPRETING AN ECG STRIP
1 small square=0.04 second
1 big square=0.2 second

1. Evaluate the P-Wave

• Must be present and upright
• One P-Wave prior to every QRS Complex

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COMMON ECG FINDINGS
References
1. Hybrid imaging in cardiovascular medicine, Liu, Yi-
Hwa; Sinusas, Albert J. (editor)
2. The ESC textbook of cardiovascular imaging, 3rd
ed., Zamorano, Jose Luis et al. (editor)
3. Cardiovascular imaging and image analysis, El-
Baz, Ayman S.; Suri, Jasjit S (editor)
4. The Johns Hopkins University, The Johns Hopkins
Hospital, and Johns Hopkins Health System
5. Prof. Rose Dyane F. Nunag, RMT, MPH., Lecture
Notes
6. Prof. Fie Maderazo, RMT., Lecture Notes
7. Osmosis from Elsevier
Atrial Fibrillation
• Irregular R-R intervals
• Atria pools blood
• Increased risk for Clots
Atrial Flutter
• Regular R-R intervals
• Sawtooth appearance in between R-R’s
• Increased risk for Clots
Ventricular Tachycardia
• No contraction, no cardiac output = fatal
• Tombstone appearance of waveforms

Ventricular Fibrillation
• Rapid, disorganized pattern of electrical activity
in the ventricle = cardiac arrest

Other points to consider:

• Standard paper speed for ECG tracings: 25
millimeters per second (mm/s).
• Paper speed represents the rate at which ECG
paper moves through the machine during
recording.
• Calibration ensures accurate measurements of
voltage and time.
Voltage calibration standard: 10 millimeters (mm)
per millivolt (mV) vertically.
Horizontal calibration standard: 1 millimeter per
second (mm/s).
• Adhering to standard settings enables accurate
interpretation of ECG waveforms and
measurements.
• Facilitates identification of abnormalities and
informed clinical decision-making.

Electrocardiogram | Ortega, Julianne