Electrocardiogram (ECG/EKG)

Electrocardiogram (ECG/EKG)

• When the cardiac impulse passes through the heart, electrical current also
spreads from the heart into the adjacent tissues surrounding the heart. A small
portion of the current spreads all the way to the surface of the body. If electrodes
are placed on the skin on opposite sides of the heart, electrical potentials
generated by the current can be recorded
Usage of the EKG

•Gold standard for diagnosis of cardiac arrhythmias

• Helps detect electrolyte disturbances (hyper- &
hypokalemia)
• Allows for detection of conduction abnormalities
• Screening tool for ischemic heart disease during stress
tests
• Helpful with non-cardiac diseases (e.g. pulmonary
embolism or hypothermia)
Connections of the body with the electrocardiograph for recording chest leads.
ECG Graph Paper
• Runs at a paper speed of 25 mm/sec
• Each small block of ECG paper is 1 mm2
• At a paper speed of 25 mm/s, one small block equals 0.04 s
• Five small blocks make up 1 large block which translates into 0.20
s (200 msec)
• Hence, there are 5 large blocks per second
• Voltage: 1 mm = 0.1 mV between each individual block vertically
Characteristics of the Normal Electrocardiogram
 3 distinct waves are produced during cardiac cycle
 P wave caused by atrial depolarization
 QRS complex caused by ventricular depolarization
 T wave results from ventricular repolarization
Elements of the ECG:
• P wave
• Depolarization of both atria;
• Relationship between P and QRS helps distinguish various
cardiac arrhythmias
• Shape and duration of P may indicate atrial enlargement
•QRS complex:
• Represents ventricular depolarization

• Larger than P wave because of greater muscle mass of

ventricles
• Normal duration = 0.08-0.12 seconds
• Its duration, amplitude, and morphology are useful in
diagnosing cardiac arrhythmias, ventricular hypertrophy, MI
(Myocardial infarction ), electrolyte derangement, etc.
• Q wave greater than 1/3 the height of the R wave, greater than
0.04 sec are abnormal and may represent MI
• PR interval:
• From onset of P wave to onset of QRS
• Normal duration = 120-200 ms (3-4 horizontal boxes)
• Represents atria to ventricular conduction time (through His
bundle)
• Prolonged PR interval may indicate a 1st degree heart block
T wave:
• Represents repolarization or recovery of ventricles
• Interval from beginning of QRS to apex of T is referred to
as the absolute refractory period
ST segment:
• Connects the QRS complex and T wave
• Duration of 80-120 msec

QT Interval
• Measured from beginning of QRS to the end of the T wave
• Normal QT is usually about 0.40 sec
• QT interval varies based on heart rate
ECG
 3 distinct waves are
produced during
cardiac cycle
 P wave caused by
atrial depolarization
 QRS complex caused
by ventricular
depolarization
 T wave results from
ventricular
repolarization

Fig 13.24
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Types of ECG Recordings
 Bipolar leads record
voltage between
electrodes placed on
wrists & legs (right leg is
ground)
 Lead I records between
right arm & left arm
 Lead II: right arm & left leg
 Lead III: left arm & left leg

 Einthoven’s Triangle.
Einthoven’s law
 if the electrical potentials
of any two of the three
bipolar limb
electrocardiographic
leads are known at any
given instant, the third
one can be determined
mathematically by simply
summing the first two.
 Einthoven's law: I + III =
II
Chest Leads Usually six standard chest leads are
recorded, one at a time, from the anterior
chest wall.
Because the heart surfaces are close
to the chest wall, relatively minute
abnormalities in the ventricles, can cause
marked changes in ECG of chest leads.
 Electrocardiographic Interpretation of Heart Defect

Ischemic Heart Disease

 Is most commonly due to atherosclerosis in

coronary arteries
 Ischemia occurs when blood supply to tissue is
deficient
 Causes increased lactic acid from anaerobic metabolism
 Often accompanied by angina pectoris (chest pain)

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 Ischemic Heart Disease
 Detectable by changes in S-T segment of ECG
 Myocardial infarction (MI) is a heart attack
 Diagnosed by high levels of creatine phosphate (CPK) & lactate
dehydrogenase (LDH)

Fig 13.34

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 Arrhythmias Detected on ECG
 Arrhythmias are abnormal heart rhythms
 Heart rate <60/min is bradycardia; >100/min is
tachycardia

Fig 13.35

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 Arrhythmias Detected on ECG continued
 In flutter contraction rates can be 200-300/min
 In fibrillation contraction of myocardial cells is
uncoordinated & pumping ineffective
 Ventricular fibrillation is life-threatening
 Electrical defibrillation resynchronizes heart by depolarizing all cells at
same time

Fig 13.35

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Arrhythmias Detected on ECG continued
 AV node block occur when node is damaged
 First–degree AV node block is when conduction through AV node >
0.2 sec
 Causes long P-R interval
 Second-degree AV node block is when only 1 out of 2-4 atrial APs
can pass to ventricles
 Causes P waves with no QRS
 In third-degree or complete AV node block no atrial activity passes to
ventricles
 Ventricles driven slowly by bundle of His or Purkinjes

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 Arrhythmias Detected on ECG continued
 AV node block occurs when node is damaged
 First–degree AV node block is when conduction
thru AV node > 0.2 sec
 Causes long P-R interval
Fig 13.36

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Arrhythmias Detected on ECG continued

 Second-degree AV node block is when only 1 out

of 2-4 atrial APs can pass to ventricles
 Causes P waves with no QRS

Fig 13.36

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Arrhythmias Detected on ECG continued

 In third-degree or complete AV node block, no atrial activity

passes to ventricles
 Ventricles are driven slowly by bundle of His or Purkinjes

Fig 13.36

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Representation in culture

• In TV medical dramas, an isoelectric ECG (no cardiac electrical

activity, aka, flat line, is used as a symbol of death or extreme
medical peril.

• Technically, this is known as asystole, a form of cardiac arrest,

with a particularly bad prognosis.

• Defibrillation, which can be used to correct arrhythmias such as

ventricular fibrillation and pulseless ventricular tachycardia, cannot
correct asystole.
Abnormal ECG

Heart defect ECG Defect

Ventricular hypertrophy QRS complex with high
amplitude
Ventricular atrophy QRS complex with low
amplitude

Ischaemia and infarction Abnormal QRS complex,

ST segment elevated,
T-wave inverted.

Bundle branch block wide QRS complex due

to delayed conduction

Heart block P wave not followed by QRS

complex

1st degree delayed QRS complex

2nddegree absent QRS complex
3rd degree total AV dissosiasion
 Question Example

Increasing vagal stimulation of the

heart will cause an increase in
• a. Heart rate
• b. PR interval
• c. Ventricular contractility
• d. Ejection fraction
• e. Cardiac output
Answer

• The answer is b.
• The vagal fibers innervate the SA
and AV, decrease in conduction
velocity through the AV
• node, thus increasing the PR
interval.