Electrocardiogram

临床学院

Clinical college
Wang min
Have you ever made a ECG, can you
tell us something about it?
 section 1 Basic concepts of
clinical electrocardiography

• Electrocardiogram ： is the recording of the electrical

activity generated by the cells of the heart that reach the
body surface.
ECG leads
 ECG leads※

12 standard ECG leads

3 standard limb leads --ⅠⅡ Ⅲ

3 augmented limb leads--aVR aVL aVF

6 precordial leads--V1-V6
 ECG leads
 standard limb leads
LeadⅠ--left arm （ + ） right arm （ - ）
LeadⅡ--left leg （ + ） right arm
（-）
Lead Ⅲ--left leg （ + ） left arm
（-）

Ⅱ
 ECG leads
 Augmented limb lead
aVR--right arm （ + ） left arm +left leg （ - ）
aVL--left arm （ + ） right arm +left leg （ - ）
aVF--left leg （ + ） left arm +right arm （ - ）

(L)
 ECG leads
 precordial leads※
V1--right sternal margin,fourth intercostal space
V2--left sternal margin,fourth intercostal space
V3--midway between V2 and V4
V4--left midclavicular line ,fifth intercostal space
V5--left anterior axillary line,fifth intercostal space
V6--left midaxillary line,fifth intercostal space
 ECG leads※

red yellow
↑

V6
V1 V5

V2
→
black
→ green
V3
V4
 ECG leads

Cardiac impulse conduction

sinoatrial node →atrioventricular node →Bundle of His

→the right and left bundle branches →Purkinje cells

 ECG leads

Cardiac impulse formation

• P wave --activation of the atria

• PR segment--electrical recovery of the atria
• QRS complex--activation of the right and left
ventricles
• ST segment--the end of ventricular activation and
the beginning of ventricular recovery
• T wave--recovery of the ventricles
 The QRS complex
Normal electrocardiogram
Normal electrocardiogram
 Normal electrocardiogram

 Heart rate

 regularity in the cardiac rhythm:counting the number of large

squares between cycles or measuing the interval between
consecutive cycles and divided this number by 60.
the interval is one-fifth of a second(0.2s)--cardiac rate 300beats/min 60/0.2
the interval is two-fifth of a second(0.4s)-- cardiac rate150beats/min 60/0.4

 irregularity in the cardiac rhythm:the number of cycles over a

particular interval of time should be counted to determine the
average cardiac rate.
HR=60/(0.04*12)=125 beats/min

HR=60/(0.04*29)=52 beats/min
 Normal electrocardiogram

 Mean QRS axis

1.Definition:describes the general direction in the frontal plane
toward which the QRS complex is predominantly pointed.

2.Calculation:in the ECGs of most normal people ,the axis lies

between -30 °and +100°

3.Axis devation: LAD--an axis of -30 °or more negative

RAD--an axis of +100°or more positive
 Normal electrocardiogram

 Mean QRS axis

4.Clinical significance:
RAD--in the ECGs of normal hearts
RVH
myocardial infarction of the lateral wall of the left ventricle
LAD-- LVH
left anterior hemiblock
left bundle branch block
Normal electrocardiogram

• P wave
• P-R interval
• QRS complex
• ST segment
• T wave
• Q-T interval
• U wave
 Normal electrocardiogram

 Normal P wave

Atrial Activation

Right Atrium
Interatrial Septum
Left Atrium

P Wave Duration
P

0-40 m s
 Normal electrocardiogram

 Normal P wave
first upward deflection

represents atrial depolarization

negtive in lead aVR,positive in leadⅡ Ⅲ aVF

duration is normally 0.08-0.11s

＜ 0.25mV in limb leads

＜ 0.2 mV in precordial leads

 Normal electrocardiogram

 The PR interval
 Normal electrocardiogram

 The PR interval

electrical impulse travel from the atrial myocardium to

ventricular myocardium

duration is normally from 0.12 to 0.20s

varies with the heart rate

 Normal electrocardiogram

 Normal QRS complex

Ventricular Activation

IV Septum
Right, Left Free Walls
A-V Groove

QRS Duration
QRS

190-250 ms
 Normal electrocardiogram

 Normal QRS complex

Composition of 3 WavesQ, R & S,represents ventricular depolarization.

normally range from 0.08-0.11s.
positive R wave increase in amplitude and duration from V1 to V6.
S wave large in V1,larger in V2,and then progressively smaller from V3
through V6.
lead aVR normally records a predominantly negative QRS complex.
Ⅱ Ⅲ aVF,show qR-type complexes.
 Normal electrocardiogram

 Normal QRS complex

low QRS amplitude occurs when the overall amplitude is no more than
0.5mV in any of the limb leads and no more than 0.8mV in any of the
precordial leads.
in V1-V3,the presence of any Q wave is abnormal .
the altitude of normal Q wave would be in each lead ＜ 1/4 R wave .
the absence of small Q waves in leads V5 and V6 is abmormal.
 Normal electrocardiogram

 Normal ST segment
 Normal electrocardiogram

 Normal ST segment

representing the early phase of ventricular repolarization.

slightly deviations (generally elevation less than 0.1mV and

depression less than 0.05mV) may be seen normally
 Normal electrocardiogram
 Normal T wave

Repolarization

Refractory Period
Rest Phase
Non-excitability

QT Duration

250-450 ms
 Normal electrocardiogram
 Normal T wave

T wave follows the direction of the main QRS deflection.

the normal T wave is always negative in lead aVR but positive in leadⅡ.
left -sided chest leads such as V4 to V6 normally always show a
positive T wave .
T wave do not exeed 0.5 mV in any limb lead or 1.5 mV in any
precordial lead except lead Ⅲ aVL aVF and V1 to V3
the altitude of T wave is more than 1/10 R wave of the same lead.
 Normal electrocardiogram

 QT interval

QT interval
 Normal electrocardiogram

 QT interval

measures the duration of electrical activation and recovery of the

ventricular myocardium

varies with the cardiac rate.

the upper limit of the duration of the QTc interval is approximately

0.44s
 Normal electrocardiogram

 U Wave

following the T wave

oriented in the same direction as the T wave

approximately 10% of the amplitude of the T wave

the source of U wave is uncertain.

atrial depolari Ventricular de Ventricular slow Atrial depolarizatio Ventricular depolar
zation polarization and fast repolariz n to the beginning ization and repolari
ation of ventricle depolar zation
ization
Exercises
1. The QRS complex represents( )   

A. ventricular repolarization    
B. ventricular depolarization    
C. ventricular contraction    
D. ventricular filling 

B
2. The T wave represents ( )    

A. atrial depolarization     
B. atrial repolarization    
C. ventricular depolarization     
D. ventricular repolarization

D
3. The duration of a normal QRS is( )

A. 0.06~0.08s     
B. 0.08~0.10s    
C. 0.06~0.10s     
D. 0.08~0.11s 

D
4. ( ) lead placed in the left midclavicula
r line , fifth intercostal space.

A. V2
B. V3
C. V4
D. V5

C
5.When QRS complex is composed of on
ly one negative wave ,we called( ) .

A. qRs wave
B. QS wave
C. QR wave
D .Qr wave