ECG – GENERAL AND NORMAL

ASPECTS
 
ECG
 The recording of the heart’s electrical activity by several surface electrodes
placed in designated spots on the body is called an electrocardiogram.
 The investigation is called electrocardiography.

 The apparatus is called electrocardiograph (Einthoven – 1903).

 The galvanometer quantifies electrical potential variations and „translates”

potential variations in a graphic mode;
 potentialdifferences => waves (= deflections)
 no potential differences => isoelectrical line

 The millimetric paper is rolled out with a speed of

25 mm/s, therefore 1mm in horizontal line is 0.04’’(seconds);
 calibration button: 1mV = 10 mm (1 mm=0.1mV)
THE SURFACE ELECTRODES

 for frontal leads

 right arm – Red

 right foot – Black
 left arm – Yellow
 left foot – Green
THE SURFACE ELECTRODES
 for precordial leads

 V1 – intercostal space IV, right parasternal

 V2 – intercostal space IV, left parasternal

 V3 – between V2 andV4

 V4 – intercostal space V mid-clavicular line

 V5 – intercostal space V anterior axillary line

 V6 – intercostal space V mid-axillary line

 V7 and V8 intercostal space V posterior axillary line and

the line that goes through inferior angle of the scapulae
(optional)
THE SURFACE ELECTRODES FOR
PRECORDIAL LEADS
 FRONTAL BIPOLAR LEADS
 Both electrodes used for each derivation are exploring electrodes.

 Lead I uses the electrode on left arm as a (+) electrode and the electrode on the right arm as a
negative electrode. LI axis is the imaginary line that unites the 2 electrodes, and is parallel
with the ground. In the middle of the segment that unites the 2 electrodes is considered the
point 0 (electric) of LI axis. From point 0 of the axis to left arm electrode is the positive
segment of the axis, from point 0 to right arm electrode is the negative part of the axis.

 Lead II uses the electrode on left leg as a (+) electrode and the electrode on the right arm as a
negative electrode. LII axis is the imaginary line that unites the 2 electrodes. In the middle of
the segment that unites the 2 electrodes is considered the point 0 of LII axis. From point 0 to
left leg electrode is the positive segment of the axis, from point 0 to right arm electrode (the
negative electrode) is considered the negative part of the axis.

 Lead III uses the electrode on left leg as a (+) electrode and the electrode on the left arm as a
negative electrode. LIII axis is the imaginary line that unites the 2 electrodes. In the middle
of the segment that unites the 2 electrodes is considered the point 0 of LIII axis. From point 0
to left leg electrode is the positive segment of the axis, from point 0 to left arm electrode is
considered the negative part of the axis
FRONTAL BIPOLAR LEADS
FRONTAL UNIPOLAR LEADS (AUGMENTED
LEADS)

 An unipolar lead uses an exploring electrode and a so-

called indifferent electrode
 The indifferent electrode is placed in a artificial point of
0-electric created by the apparatus; this artificial point 0
is called „central terminal” and sits theoretically in the
center of the electric field of the heart.

• aVF (F = Left Foot)

• aVR (= Right arm)
• aVL (= Left arm)
 aVR lead has the exploring electrode on right arm and the other electrode in
central terminal so in the point 0 of the heart’s electric field. aVR axis is the
imaginary line that unites these two electrodes. The sense of aVR is from
central point of heart’s electric field towards up and right. From point 0
towards exploring electrode is the positive segment of the axis; the opposite
part is the negative part.

 aVL lead has the exploring electrode (+) on left arm and the other electrode
in central terminal, in the point 0 of the heart’s electric field. aVL axis is the
imaginary line that unites these two electrodes. The sense of aVL axis is from
central point of heart’s electric field towards up and left . From point 0
towards exploring electrode is the positive segment of axis; the opposite part
is the negative part.

 aVF lead has the exploring electrode (+) on left foot and the other electrode in
central terminal so in the point 0 of the heart’s electric field (= central point of
the electric field of the heart). aVF axis is the imaginary line that unites these
two electrodes. The sense of aVF axe is from up towards down, vertically.
From point 0 towards exploring electrode is the positive segment of axis; the
opposite part is the negative part.
• aVF, aVL and aVR are united in the central
point of electric field and form angles of
60°
• By combining all six frontal axes, the hexa-
axial system is obtained.
• In this system the axes form angles of 30°
between them and there are 3 pairs of
perpendicular axes: LI with aVF, LII with
aVL and LIII with aVR.
• The sense of the axis is toward positive =
towards the positive electrode for bipolar
derivation and towards exploring electrode for
unipolar derivation.
• The sense of the axis (and the positive
segment) is marked by an arrow.
• LI and aVL are called left or lateral leads;
• LII, LIII and aVF are called inferior leads.
THE HEXA-AXIAL SYSTEM
HORIZONTAL PLANE LEADS =
PRECORDIAL LEADS
 V1, V2, V3, V4, V5, V6
 *V3R, V4R, V5R = that use points situated symmetrical
to V3, V4 and V5 points, on the right side of the thorax;
they are used if a myocardial infarction of the right
ventricle is suspected
 **V7, V8 and V9 – the exploring electrodes are situated
in left fifth intercostal space: in the posterior axillary
line-V7, inferior angle of scapula line-V8 and
paravertebral-V9; they are used if a myocardial
infarction of the posterior wall is suspected.
HORIZONTAL PLANE LEADS

V1 and V2 are considered right precordial leads - they “see” the right ventricle and
the septal surface of the heart (interventricular septum);
V3 and V4 are considered anterior precordial leads – they “see” anterior wall of the
left ventricle and the apex
V5 and V6 are considered left (or lateral) precordial leads – they “see” the lateral
wall of the left ventricle
NORMAL DEPOLARIZATION
 It is generated first in the sino-atrial node (SA) = the cardiac pace-maker –
which it is situated in the right atrium (RA).
 The depolarization is propagated to and by the atrial myocardial cells (velocity =
1 m/s).
 Then the depolarization arrives at AV node (velocity = 0.2 m/s); the AV node is
normally the only access for electrical impulses between atria and ventricles, but
besides this, it also has the role of delaying the spread of depolarization from
atria to ventricles (so the ventricles are able to contract after the atria).
 From AV node the depolarization is spread to His bundle and His bundle
branches, to Purkinje cells (here the speed is very high = up to 4m/s) and then
to ventricular cells.
 Because they are in the vicinity of Purkinje fibers, the first myocardial cells
that are depolarized in the ventricular muscle are the subendocardial cells.
 Then the electrical impulse travels in the middle zone of myocardial muscle and
finally arrives in the subepicardial region.
Because the SA node has the
faster auto activation rate, it
becomes the leader, the pace-
maker.

 ***Other cells than those of sinoatrial node can exhibit in certain situation
pace-maker activity but they have a normally slower activity: AV node
cells, cells of His bundle and cells of its ramifications.
 SA node cells have the normal capacity to auto depolarize, usually at 60 to 100
times per minute.
 AV node can achieve a spontaneous auto activation with a frequency of 50-
40/minute,
 Purkinje fibers a frequency of 25/minute.  
REPOLARIZATION

 Unlike depolarization, the repolarization is not propagated through the

conduction tissue, but from one miocardic cell to another. It is a slower process,
but not a passive one (it consumes energy). Also, repolarization is not a mirror-
image of depolarization.
 Atrial repolarization is a slow process and doesn’t involve an important mass of
cells so it isn’t usually observed in ECG.
 Ventricular repolarization, although also a slower process than ventricular
depolarization, involves a greater number of myocardial cells and has a graphic
expression.
 Although it may seem logical that the first cells that are depolarized should be
the first cells to be repolarized, it isn’t what happens in normal situations and
that is because the subepicardial cells and subendocardial cells have different
potassium channels;
 potassium channels involved in repolarization of subepicardial cells are
faster than those of subendocardial cells therefore repolarization begins in
subepicardial regions and ends in subendocardial regions.
CARDIAC VECTORS
 are oriented from (-) electric charge towards (+) electric charge
 The resultant vector of the whole atrial depolarization;
 the right atrial (RA) depolarization vector;
 the left atrial (LA) depolarization vector.

 Septal depolarization vector

 Depolarization vector of the lateral wall of the right ventricle
(RV);
 Apex depolarization vector

 Depolarization vector of the lateral wall of the left ventricle (LV)

 Basal depolarization vector

 The resultant vector of ventricular repolarization (= the electric

axis of the heart)
RELATIONSHIP OF CARDIAC
VECTORS WITH DERIVATION AXES:
 A lead will “see” a vector by the projection of this particular vector on
that lead. The vector is translated in the axial system (of the frontal plane
or of the horizontal plane) with its origin point in the 0 point of the
system. From the tip of the vector a perpendicular line to an axis is then
drawn.
 If the vector projects on the positive part of the axis it will determine a
positive wave (= a wave situated above the isoelectric line);
 If the vector is projected on the negative segment of the axis a negative
deflection (= a wave situated below the isoelectric line) is registered on
ECG course.
 The magnitude of the projection depends on the angle between the vector
and the lead:
a parallel vector determines the biggest projection;
 a perpendicular vector determines the smallest projection (a point) or an
equiphasic complex.
NORMAL ATRIAL DEPOLARIZATION – THE P WAVE

 The aspect of P wave depends on how the atrial depolarization

vector is projected on the respective lead.
 In frontal plane:

Atrial depolarization vector; RA and LA The atrial depolarization vector projects on positive parts of DI, aVF, DII (evidentiated
depolarization vectors by positive P waves in these leads); and on the negative segment of aVR (the P wave
is negative in aVR).
  In horizontal plane:

In V1 and V2 the normal P wave is frequently biphasic with a In V3, V4, V5, V6 the normal P wave is positive.
first positive phase that is the projection of RA depolarization
vector and a second negative part that is the expression of LA
depolarization.
NORMAL VENTRICULAR
DEPOLARIZATION – THE QRS
COMPLEX
 The first areas that undergo depolarization are the subendocardial
ones, so ventricular depolarization occurs from the subendocardial
regions to the subepicardial regions.
 Septal depolarization vector is oriented from left to right slightly
down and from posterior to anterior.
 Apex depolarization vector is oriented from right to left and
downwards
 Depolarization vector of the lateral wall of the left ventricle (LV) is
oriented from right to left and from anterior to posterior.
 Basal depolarization vector is oriented from right to left, upwards
and from anterior to posterior.
 There is a physiological asynchronism in ventricular depolarization: RV
depolarization begins and ends before LV depolarization
NORMAL VENTRICULAR REPOLARIZATION –
THE T WAVE
 The repolarization process doesn’t start from endocardial areas but from
epicardial areas (these cells have a shorter action potential due to high
permeability K channels)
 Because repolarization starts in subepicardial cells, these cells are the first to
become electropositive, while subendocardial cells are still electronegative.
 The repolarization vectors are therefore oriented from inside (-) towards outside(+).
 The repolarization vector
is oriented from up-right
to down-left
(opposite to the direction
of the repolarization front)
NORMAL ECG WAVES:
 P wave
 in frontal leads - positive, with the exception of aVR (where is negative), with
maximum height in D II
 in precordial leads
 V1, V2 = positive or equiphasic

 (with first complex positive) or negative

 positive in V3, V4, V5, V6

 QRS complex
 in frontal leads: positive (usually) with the exception of aVR
 in precordial leads: in V1 aspect rS and in V6 aspect qRs

 T wave – usually consistent with QRS complex

 in frontal leads: positive (usually) with the exception of aVR
 in precordial leads usually positive (exception: in children, adolescents, young adults
when it may be negative in V1, V2 and even V3)
 U wave – visible sometimes after T wave is caused by stretch mediated
depolarization of the ventricular myocardia during diastolic filling.
ECG I
ECG II
ECG III