THE ELECTROCARDIOGRAM

The electrocardiogram is a graphical recording of the electrical activity of the heart. It

records cardiac electrical currents (voltages, potentials) by means of metal electrodes placed
on the body surface. These electrodes are placed arms, legs and chest wall.

Each heart beat results in 3 "waves" or deflections on an ECG. The electrical activation
(depolarization) of the upper chambers of the heart (the atria) results in the low amplitude P
wave. The subsequent electrical activation (depolarization) of the lower chambers of the heart
(the ventricles) results in the high amplitude QRS complex. Repolarization of the atria is a low
amplitude signal that occurs during the time of the high amplitude QRS and consequently, is not
seen on a standard ECG. Repolarization of the ventricles results in the T wave.

The flat lines before the P wave, between the P and QRS and after the T wave are said to be at
the baseline of that ECG tracing. The line connecting the QRS to the T wave is called the ST
segment and is normally quite close to the baseline.

A QRS complex can have positive (upwards) or negative (downwards) deflections. If it starts
with an initial negative deflection, that deflection is called a Q wave. The first upward
deflection is called R wave. A negative deflection following an R wave is called an S wave. If
there is only one negative deflection without an R wave, that is called a QS complex. A second R
wave following an S wave is called an R' ("R-primed") wave. The above tracing shows a large R
wave and small S wave.

Time is represented on the horizontal, x-axis on ECGs. The distance between 2 vertical lines is 1
millimetre representing 0.04 seconds with a recorder sweep speed of 25 millimetres per sec.

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The vertical, y-axis represents the amplitude or strength of the electrical signal in millivolts.
Horizontal lines are also 1 spaced millimetre apart. Each horizontal line represents 0.1 millivolts.

The heart rate is calculated by dividing 60,000 by the time (in milliseconds) between 2
consecutive R waves.

The time it takes for electricity to be conducted from the atria to the ventricles is
represented by the PR interval. This is measured from the beginning of the P wave to the
beginning of the QRS complex.

The time it takes for the ventricles to become electrically activated is represented by the QRS
duration. This is measured from the beginning of the QRS to the end of the QRS.

The total amount of time the ventricles are electrically active (from onset of depolarization to
completion of repolarisation) is represented by the QT interval. This is measured from the
onset of the QRS to the end of the T wave.

The voltage of the P wave and QRS complex is proportional to the total amount of muscle being
depolarized. A higher than normal voltage implies overgrowth of the muscle of that chamber.
Since the left ventricle has a lot more muscle than the right ventricle, the QRS complex
primarily represents electrical events of the left ventricle.

This diagram illustrates ECG waves and intervals as well as standard time and voltage measures on the ECG paper.

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ECG Waves and Intervals:

P wave: the sequential activation (depolarization) of the right and left atria

QRS complex: right and left ventricular depolarization (normally the ventricles are activated
simultaneously)

ST-T wave: ventricular repolarisation

U wave: origin for this wave is not clear - but probably represents "after-depolarisations" in
the ventricles

PR interval: time interval from onset of atrial depolarization (P wave) to onset of ventricular
depolarization (QRS complex)

QRS duration: duration of ventricular muscle depolarization

QT interval: duration of ventricular depolarization and repolarisation

RR interval: duration of ventricular cardiac cycle (an indicator of ventricular rate)

PP interval: duration of atrial cycle (an indicator of atrial rate)

An actual ECG is recorded by placing electrodes on each limb and 6 electrodes on the chest.

This allows the recording of 12 ECG leads:

Lead I treat the right arm as negative and left arm as positive.

Lead II treats the left arm as negative and the left leg as positive.

Lead III treats the right arm as negative and the left leg as positive.

Lead aVR treats the right arm as positive and the other limb electrodes as negative.

Lead aVL treats the left arm as positive and the other limb electrodes as negative.

Lead aVF treats the left foot as positive and the other limb electrodes as negative

The first chest lead is called V1 and is placed just to the right of the breastbone. Chest lead
V2 is placed just to the left of the breastbone. Chest leads V3 through V6 are sequentially
further to the left.

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Each of the 6 chest leads is a positive lead. The patient's back is considered the negative
electrode for each.

Orientation of the 12 Lead ECG

The 12-lead ECG provides spatial information about the heart's electrical activity in 3
approximately orthogonal directions:

Right Left

Superior Inferior

Anterior Posterior

Each of the 12 leads represents a particular orientation in space, as indicated below (RA = right
arm; LA = left arm, LF = left foot):

Bipolar limb leads (frontal plane):

Lead I: RA (-) to LA (+) (Right Left, or lateral)

Lead II: RA (-) to LF (+) (Superior Inferior)

Lead III: LA (-) to LF (+) (Superior Inferior)

Augmented unipolar limb leads (frontal plane):

Lead aVR: RA (+) to [LA & LF] (-) (Rightward)

Lead aVL: LA (+) to [RA & LF] (-) (Leftward)

Lead aVF: LF (+) to [RA & LA] (-) (Inferior)

Unipolar (+) chest leads (horizontal plane):

Leads V1, V2, V3: (Posterior Anterior)

Leads V4, V5, V6: (Right Left, or lateral)

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 Lead placement

Einthoven's Triangle! Each of the 6 frontal plane leads has a negative and positive orientation
(as indicated by the '+' and '-' signs). It is important to recognize that Lead I (and to a lesser
extent Leads aVR and aVL) are right left in orientation. Also, Lead aVF (and to a lesser extent
Leads II and III) are superior inferior in orientation. The diagram below further illustrates the
frontal plane hook-up.

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Location of chest electrodes in 4th and 5th intercostal spaces:

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V1: right 4th intercostal space

V2: left 4th intercostal space

V3: halfway between V2 and V4

V4: left 5th intercostal space, mid-clavicular line

V5: horizontal to V4, anterior axillary line

V6: horizontal to V5, mid-axillary line

A standard ECG machine records leads I, II and III simultaneously, then aVR, aVL, and aVF
simultaneously, then V1, V2, and V3 simultaneously and finally V4, V5, and V6 simultaneously:

This 12 lead ECG recorded 3 heart beats from I, II, III; 3 beats from aVR, aVL, aVF; 3 beats from V1, V2,
V3 and 4 beats from V4, V5, V6. You should be able to recognize a QRS complex for each beat in each lead and, in
most leads, a preceding P wave and subsequent T wave.

The electrical signal that starts in the atria and travels down to the ventricle is of course
moving through three dimensions. Each lead inscribes a positive deflection for that component
of the net electrical vector that is travelling towards its positive electrode and a negative
deflection for that component of the net electrical vector that is travelling towards its
negative electrode. Thus, by knowing the position of each lead, you can determine the direction
the electrical signal is travelling. Looking at the heart's electrical activity with 12 leads is like
looking at a three dimensional object from 12 different angles.

Different lead sets "look" at different parts on the heart. Leads II, III and aVF all treat the
foot electrodes as positive and thus reflect activity at the bottom or inferior wall of the heart.

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Leads I, aVL, V5 and V6 have their positive electrodes on the left side of the body and thus
reflect activity of the left-most (lateral) wall of the heart.

Leads V1, V2, V3 and V4 have their positive electrodes on the front of the body and thus
reflect activity of the front (anterior wall) of the heart.

Three basic laws of electrocardiography

A positive upward deflection appears in any lead if the wave of depolarisation spreads towards
the positive pole of that lead. Thus if the path of atrial stimulation is directed downward and to
patients left, towards the positive pole of lead II a positive p wave is seen in lead II.
A negative downward deflection appears in any lead if the wave of depolarisation spreads
towards the negative pole of that lead (or away from +ve pole). If the ventricular stimulation
path is directed entirely away from positive pole from any lead, a negative QRS (QS deflection)
complex is seen.
If the mean depolarisation path is directed right angle to any lead, a small biphasic deflection
(consisting of +ve and –ve deflections of equal size) is usually seen. If the ventricular
stimulation path spreads at right angles to any lead, the QRS complex is biphasic. It may
consist of either an RS pattern or a QR pattern.

Characteristics of the Normal ECG

It is important to remember that there is a wide range of normal variability in the 12 lead ECG.
Topics for Study:

1. Measurements
2. Rhythm
3. Conduction
4. Waveform description

1. Measurements

Heart Rate: 60 - 90 bpm

Because ECG paper moves at a standardized 25mm/sec, the vertical lines can be used to
measure time. There is a 0.20 sec between 2 of the large lines. Therefore, if you count the
number of heart beats (QRS complexes) in between 30 large boxes (6 seconds) and multiply by
10, you have beats per minute. Conveniently, ECG paper usually has special markings every 3
seconds so you don't have to count 30 large boxes.

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There is, however, an easier and quicker way to estimate the heart rate. As seen in the diagram
below, when QRS complexes are 1 box apart the rate is 300 bpm. 2 boxes apart...150 bpm, etc.
So if you memorize these simple numbers you can estimate the heart rate at a glance!

PR Interval: 0.12 - 0.20 sec

QRS Duration: 0.06 - 0.10 sec
QT Interval (QT < 0.40 sec)
c

Bazett's Formula: QT = (QT)/SqRoot RR (in seconds)

c

Poor Man's Guide to upper limits of QT: For HR = 70 bpm, QT<0.40 sec; for every 10
bpm increase above 70 subtract 0.02 sec, and for every 10 bpm decrease below 70 add 0.02
sec. For example:

QT < 0.38 @ 80 bpm

QT < 0.42 @ 60 bpm

Frontal Plane QRS Axis: +90 to -30 (explained latter)

o o

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2. Rhythm:

Normal sinus rhythm

The P wave in leads I and II must be upright (positive) if the rhythm is coming from the sinus
node.

3. Conduction:

Normal Sino-atrial (SA), Atrioventricular (AV) and Intraventricular (IV) Conduction

Both the PR interval and QRS duration should be within the limits specified above.

4. Waveform Description:

(Normal ECG is shown below - Compare its waveforms to the descriptions below)

¾ P Wave

The normal p wave represents atrial depolarisation, is the 1st waveform seen in any cycle. It is
important to remember that the P wave represents the sequential activation of the right and
left atria, and it is common to see notched or biphasic P waves of right and left atrial activation.
The atrial depolarisation path therefore, spreads from right to left and downward towards AV
junction i.e. away from the positive pole of aVR, therefore, with normal sinus rhythm this lead
shows a negative P wave. But conversely, lead II records a positive P wave.
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 P duration < 0.12 sec

P amplitude < 2.5 mm

Frontal plane P wave axis: 0 to +75

o o

May see notched P waves in frontal plane

QRS Complex

The QRS represents the simultaneous activation of the right and left ventricles, although
most of the QRS waveform is derived from the larger left ventricular musculature.
Although the spread of atrial depolarisation can be represented by a single arrow, the
spread of ventricular depolarisation consists of 2 major sequential phases:

1. The first phase of ventricular depolarisation is of relatively brief duration (>.04 m

sec.) and small amplitude, resulting from the spread of stimulus through the
interventricular septum. The left side of septum is stimulated first, thus
depolarisation spreads from left to right ventricle across the septum. This is
represented by a small arrow from left septal wall to right.
2. The second phase of ventricular depolarisation involves simultaneous stimulation of
main mass of both left and right ventricles from inside to outside. In normals the left
heart is electrically predominant, thus the arrow points towards the left ventricle.

Chest leads

The first phase of ventricular stimulation represented by a small arrow pointing towards the
right. This arrow points towards +ve pole of V1, Thus produces a small +ve deflection (r- wave).
But this also produces a small –ve (q wave) in V6.
The 2nd phase as represented by arrow towards left, points away from +ve pole of V1.
Therefore, results in a negative deflection in right precordial leads and positive in the left.
Thus with normal QRS pattern, lead V1 shows an rS type of complex. The small r wave is
sometimes referred to as septal r wave. Conversely, viewed from an electrode in V6 position,
septal ventricular stimulation produces a q wave. Between V1 to V6 as one moves across the
chest, the r wave tends to become relatively larger and s wave becomes relatively smaller. The
increase in r wave reaching max in V4 or V5 is called normal r wave progression. The point where
r wave equals s wave, usually V3 or V4, is called the transition zone. Leads V5 and V6 generally
show qR type of complex.

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Limb leads

The ventricular stimulation forces are primarily oriented towards left ventricle, therefore aVR
shows a predominant –ve QRS complex. It may display an rS complex, a QS complex, or a Qr
complex. The T wave is also normally negative.

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The QRS complex in other 5 leads is somewhat complicated. The reason being that QRS
patterns in extremities show considerable normal variation. The patterns that are seen depend
upon electrical position of the heart. This electrical position of the heart may be described as
either horizontal or vertical:

When heart is electrically horizontal (horizontal QRS axis), ventricular depolarisation is

directed mainly horizontally and to the left in the frontal plane. Thus tall r waves are usually
seen (as part of qR complex) is seen in these leads.
When heart is electrically vertical, ventricular depolarisation is directed mainly downwards.
Thus QRS voltages are directed towards leads II, III and aVF shows rS or RS complexes
similar to those seen in right chest leads normally.

Therefore, when the heart is electrically horizontal, the patterns in leads I and aVL resemble
those in V5 and V6 whereas the patterns in leads II, III and aVF resemble those in right chest
leads. Conversely, when the heart is electrically vertical, just the opposite patterns are seen in
extremity leads. With the vertical heart, leads I, II, III and aVF show qR complexes similar to
those seen in left chest leads, and lead I and aVL show rS type complexes resembling those in
the right chest leads.

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An intermediate heart position is referred to when leads I, II, aVL and aVF all show positive
QRS complexes. Therefore, this tracing has features of both vertical and horizontal variants.

QRS duration < 0.10 sec

QRS amplitude is quite variable from lead to lead and from person to person. Two
determinates of QRS voltages are:

Size of the ventricular chambers (i.e., the larger the chamber, the larger the voltage)

Proximity of chest electrodes to ventricular chamber (the closer, the larger the
voltage)

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 Frontal plane leads:

The normal QRS axis range (+90 o

to -30 o
); this implies that the QRS be mostly
positive (upright) in leads II and I.

Normal q-waves reflect normal septal activation (beginning on the LV septum); they are
narrow (<0.04s duration) and small (<25% the amplitude of the R wave). They are often seen in
leads I and aVL when the QRS axis is to the left of +60 , and in leads II, III, aVF when the
o

QRS axis is to the right of +60 . Septal q waves should not be confused with the pathologic Q
o

waves of myocardial infarction.

Precordial leads:

Small r-waves begin in V1 or V2 and progress in size to V5. The R-V6 is usually smaller
than R-V5.

In reverse, the s-waves begin in V6 or V5 and progress in size to V2. S-V1 is usually
smaller than S-V2.

The usual transition from S>R in the right precordial leads to R>S in the left precordial
leads is V3 or V4.

Small "septal" q-waves may be seen in leads V5 and V6.

ST Segment and T wave

In a sense, the term "ST segment" is a misnomer, because a discrete ST segment distinct
from the T wave is usually absent. More often the ST-T wave is a smooth, continuous
waveform beginning with the J-point (end of QRS), slowly rising to the peak of the T and
followed by a rapid descent to the isoelectric baseline or the onset of the U wave. This gives
rise to an asymmetrical T wave. In normal individuals, particularly women, the T wave is
symmetrical and a distinct, horizontal ST segment is present.
The ST segment represents early phase of ventricular repolarisation, usually isoelectric with
slight deviations (>1 mm). it can show more marked elevation as normal variant.

Ventricular repolarisation produces ST segment, T wave, and U wave.

The normal T wave is usually in the same direction as the QRS except in the right precordial
leads. In the normal ECG the T wave is always upright in leads I, II, V3-6, and always

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inverted in lead aVR. Left sided chest leads V4 – V6 usually show a +ve T wave. If the T wave
is positive in any of chest lead, it must remain +ve in all the leads left to that lead. The
polarity of the T wave depends on the electrical position of the heart.

Normal ST segment elevation: this occurs in leads with large S waves (e.g., V1-3),
and the normal configuration is concave upward. ST segment elevation with concave
upward appearance may also be seen in other leads; this is often called early
repolarisation, although it's a term with little physiologic meaning (see example of "early
repolarisation" in leads V4-6):

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 Convex or straight upward ST segment elevation (e.g., leads II, III, aVF) is abnormal
and suggests transmural injury or infarction:

ST segment depression is always an abnormal finding, although often non-specific (see

ECG below):

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 ST segment depression is often characterized as "up sloping", "horizontal", or "down
sloping".

The normal U Wave: (the most neglected of the ECG waveforms)

U wave amplitude is usually < 1/3 T wave amplitude in same lead

U wave direction is the same as T wave direction in that lead
U waves are more prominent at slow heart rates and usually best seen in the
right precordial leads.

Origin of the U wave is thought to be related to after-depolarisations which

interrupt or follow repolarisation.

Electrical axis

Mean QRS axis definition

The depolarisation stimulus spread through the ventricles in different directions from instant
to instant. The mean direction of the QRS complex, or the mean QRS electrical axis can also be
described. This axis describes the general direction in the frontal plane towards which the QRS
complex is predominantly pointed.

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As the axis is defined only in the frontal plane, the QRS is being described only in reference to
six extremity leads. Combining all the six leads making them to intersect at a same point can
produce a hex-axial lead diagram. This diagram is used to determine the mean QRS axis
deviation. The positive pole of lead I is said to be 0º, by convention. All the points below 0º are
positive, and all points above this axis are negative. By convention again the, the electrical axis
that points towards the aVL is termed leftward or horizontal. An axis that points towards the
leads II, III, and aVF is rightward or vertical.

Mean QRS axis calculation

As a general rule, the mean QRS axis points midway between any two leads that show tall R
waves of equal height. The electrical axis can be calculated a second way. If a biphasic complex
exists in any of the extremity leads, the axis must be directed at 90° to that lead. If the axis
lies at –ve side of the hexagonal scale, the depolarisation forces must be directed away from
the positive pole of that lead. Thus the lead will show a negative complex.
As a second rule, the mean QRS axis is oriented at the right angles to any lead showing a
biphasic complex. In this situation the mean QRS axis points in the direction showing tall R
waves.

Axis deviation

In the ECGs of most normal people the axis lies between -30° and +100°. An axis of -30° or
more negative is described as left axis deviation. Aix of +100° or more positive is termed as
right axis deviation. LAD is abnormal extension of the mean QRS axis found in patients with
electrical horizontal heart. And RAD is abnormal extension of mean QRS axis in persons with
electrically vertical heart. The mean QRS axis is determined by anatomic position of the heart
and direction in which stimulus spreads through ventricles (ventricular depolarisation).
The influence of cardiac anatomic position on electrical axis can be illustrated by the effects of
respiration. When a person breathes in, the diaphragm descends and the heart becomes more
vertical, shifting the axis vertically. Reverse happens when a person breathes out.
The influence of direction of ventricular depolarisation can be illustrated by left anterior hemi-
block. The spread of stimuli through more or superior and leftward portion of ventricle is
delayed and the mean QRS axis shifts to the left. In RVH the axis shifts to right.

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RAD exists if the axis is found to be < +100°. As an approximate rule, if the leads II and III
show tall R waves and R wave in III exceed that of in II RAD is present. In addition, lead I
shows R pattern with S wave deeper than R wave is tall.
LAD if QRS axis is found to be <30°. If LAD exists it shows a deep S wave, and lead II shows
either a biphasic RS complex (amplitude of S exceeding the height of R) or a QS complex.
Leads I and aVL both show R waves.
With electrically vertical heart, the actual mean QRS axis may be normal (+80°) or abnormal
rightward (+120°). Similarly with electrically horizontal heart the axis may be normal (0°) or
abnormal leftward (-50°).
RAD therefore, is simply an extreme form of a vertical mean QRS axis and LAD is an extreme
form of a horizontal mean QRS axis.
If area under QRS complex in both lead I and II is positive, the axis must be normal. If the
QRS complex is predominantly positive in lead I and negative in lead II, LAD is present.
If QRS complex is predominantly negative in lead I and positive in lead II, RAD is present.

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Clinical significance

RAD is usually suggestive of RVH, myocardial infarction of lateral wall of left ventricle, left
posterior hemi-block (rarely). Moreover, chronic lung diseases, acute pulmonary embolism may
lead to sudden shift to of axis to right (not necessarily actual RAD).
LAD is usually seen in LVH, left anterior hemi-block and also in left bundle branch block.

Mean electrical axis of P wave

The same principles can be applied to mean electrical axes of p and t wave in frontal plane.
When sinus rhythm is present, P wave is always negative in aVR and positive in lead II, making
normal P wave axis about 60°.
As a rule mean T wave axis and the mean QRS axis normally point in same general direction. E.g.
when electrical position of heart is horizontal, T waves normally are positive in lead I and aVL, in
association with tall R wave in those leads. When the electrical position is vertical, T waves are
normally positive in lead II, III and aVF.

Atrial and ventricular enlargements

Cardiac enlargement can be either dilatation of a heart chamber or hypertrophy of a heart

muscle. In hypertrophy the actual number of cells does not increase, but each cell becomes
larger in size. Thus leading to increase in voltage/duration of P waves or QRS complex.
Hypertrophy and dilatation usually occur together.

Right atrial abnormality

Dilatation/hypertrophy may increase voltage of P waves. When P wave is positive, the amplitude
is measured from upper level of baseline to the peak. If it is negative, it is measured from the
lower level of baseline to peak. Normally it is of >.25 mV and .12 m sec.
Overload of the right atrium may produce an abnormal tall wave, but RAA does not increase the
duration of atrial depolarisation. Abnormal P wave in RAA is sometimes referred to as P
pulmonale, usually best seen in leads II, III, aVF and sometimes V1. The ECG diagnosis can be
made if the P wave exceeds 2.5 m in any of these leads.

Left atrial abnormality

It also produces P wave changes. Left atrium depolarises after the right, so
enlargement/dilatation must prolong the total duration of atrial depolarisations. Thus giving rise
to a wide P wave with a characteristic duration of < .12 sec. the amplitude of the wave can be

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normal or increased. Abnormal P wave also represent an atrial conduction delay. Therefore,
rather than left atrial enlargement more general term left atrial abnormality is increasingly
being used.
P wave sometimes has distinct hump or notched appearance. The second hump corresponds to
the delayed depolarisation of left atrium. These humped P wave are best seen in one or more
extremity leads.
In patients with LAA, lead V1 sometimes shows distinct biphasic P wave with a small initial
biphasic deflection with wide negative deflection (.04 sec or 1 mm in depth). The prominent
negative deflection corresponds to the delayed stimulation of enlarged atrium.

Right ventricular hypertrophy

Although atrial enlargement may produce prominent changes in the P wave, the QRS complex is
modified primarily by ventricular hypertrophy. Normally the left and right ventricles depolarise
simultaneously, and the left ventricle is electrically predominant as a result leads placed over
the right side of the chest (e.g. V1) record rS type complexes. In these rS type complexes the
deep negative S wave indicates the spread of depolarisation voltage away from the right and
towards the left side. Conversely, leads placed over the left chest record a qR type complex.
If sufficient hypertrophy of right ventricle occurs, the normal electrical predominance of the
left ventricle can be overcome. With RVH the right chest leads show tall R waves, indicating the
spread of positive voltages from the hypertrophied right ventricles towards the right.

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An R wave exceeding the S wave in lead V1 is suggestive but not diagnostic of RVH. Along with
tall R waves, RVH often produces two additional ECG signs: right axis deviation and right
ventricular strain, T wave inversion.
RVH affects both depolarisation and repolarisation, i.e. QRS and ST complex. The
characteristic repolarisation change is the inverted T wave in the right and middle chest leads.
These right chest T wave inversions are referred to as right ventricular strain pattern.

Left ventricular hypertrophy.

Normally the left ventricle is electrically predominant over the right. When the LVH is present,
the balance of electrical forces is tipped even further to left. Thus abnormally tall R waves are
usually seen in the left chest leads, and abnormal deep negative S waves are seen in the right
chest leads.

Criteria for diagnosis of LVH

1. If the sum of the depth of S wave in lead V1 and height of R wave in either V5/V6
exceeds 35 mm, LVH should be considered.
2. An R wave of 11 to 13 mm in or more in lead aVL is another sign of LVH
3. ST-T changes are often associated with LVH. Repolarisation abnormality is seen in leads
with tall R waves.
4. With LVH the electrical axis is usually horizontal. Actually left axis deviation may be
seen. In addition QRS complex may be wider.
5. The signs of LAA are often seen in patients with ECG evidence of LVH. Most conditions
that lead to LVH ultimately produce left atrial overload as well.

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