Electrophysiology of the heart

Specialized excitatory and conductive system of the heart

1. Sino-atrial node (SA-node): Fire 80-120 x/min
2. Internodal pathways: conduct impulse from SA-
node to AV node.
3. AV-node: Site of nodal delay. Rhythm=40-60 x/min
4. Atrioventricular bundle (bundle of His):
conducts impulse from the atria to the ventricle.
Rhythm=20-40 x/min
5. Purkinje fibers: conduct cardiac impulse to the
ventricles: Rhythm=20-40 x/min

2
Electrophysiology of the heart
Phases and ionic bases of
myocardial action potential
↑PCl
It has 5-phases
Phase-0: Rapid depolarization
Caused by rapid Na-influx
Phase-1: Early partial repolarization
Caused by Cl- influx or K efflux
Phase-2: The plateau (prolonged
depolarization) RMP = -90 mv
Caused by Ca2+influx via L-
channels
Phase-3: Repolarization
Caused by K+ efflux AP of the ventricular muscle
Phase-4: complete repolarization
Refractory period of AP of
RMP re-established ventricular muscle
Caused by Na-K-ATPase
 ACTION POTENTIALS FROM DIFFERENT AREAS OF
THE HEART

ATRIUM VENTRICLE
0 0
mv

mv
-90mv
-90mv

0
mv

SA NODE
-55mv
time4
 Electrophysiology of the heart
• Cardiac impulse spreads to the adjacent tissues and to the surface.
• This can be recorded by placing electrode on the skin surface which
is called electrocardiogram (ECG).
• ECG of the heart is recorded from specific sites of the body.
• ECGs are not actually cardiac muscle AP, because those AP travel
from the S-A node.
• The electrodes are not even on the heart surface; they’re on the
skin surface.
• Monophasic AP of 110 mv directly from heart muscle membrane.
• The QRS complex usually is 1.0 to 1.5 mv from two arms or leg.
• The voltage of the P wave is between 0.1 and 0.3 millivolts, and the
voltage of the T wave is between 0.2 and 0.3 millivolts.
• ECG was developed by W. Einthoven in 1909.
 Important terminologies
• Electrocardiography
• Electrocardiograph
• Electrocardiogram
• ECG leads
• Waves
• Intervals
• Segment
• Duration
• Amplitude
• ECG paper
• Electrocardiographic grid
 Electrocardiographic calibration and display

• ECGs recordings should be made with appropriate

calibration.
• It is either printed on moving ECG paper or displayed
digitally.
• ECG paper has horizontal and vertical lines at regular
intervals of 1 mm.
• ECG is run at a speed of 25 millimetres per second,
although faster speeds are sometimes used.
• The 0.20-second intervals are then broken into five
smaller intervals by thin lines, each of which represents
0.04 second
 Waveforms of the normal ECG

• ECG is composed of both depolarization and repolarization waves.

• Depolarization waves are P wave and the QRS complex
• Th normal ECG is composed of a P wave, a QRS complex, and a T
wave.
• The QRS complex is not always, three separate waves.
• The P wave is caused by the atria depolarization.
• The QRS complex is caused by ventricular depolarization.
• The T wave is caused by ventricular repolarization.
• This process normally occurs in ventricular muscle 0.25 to 0.35
second after depolarization.
Cardiac depolarization waves versus repolarization waves
 P wave
• Produced due to the depolarization of atrial.
• Depolarization spreads from SA node to all parts of atrial
musculature.
• Atrial repolarization is not recorded as a separate wave
in ECG as it merges with QRS complex.
• Duration: 0.1 second.
Amplitude: 0.1 to 0.12 mV.
Morphology: positive (upright) in leads I, II, aVF, V 4, V5
and V6.
• It is normally negative (inverted) in aVR.
 QRS COMPLEX
• Is due to depolarization of ventricle.
• Q wave is the depolarization of basal portion of IVS.
• R wave is due to the depolarization of apical portion of
interventricular septum and apical portion of ventricular
muscle.
• S wave is due to the depolarization of basal portion of
ventricular muscle near the atrioventricular ring.
Duration: between 0.08 and 0.10 second.
Amplitude
Q wave = 0.1 to 0.2 mV.
R wave = 1 mV.
S wave = 0.4 mV.
 • Morphology
• Q wave is normally small with amplitude of 4 mm or
less.
• From chest leads V 1 to V6, R wave becomes gradually larger. It is smaller in V6
than V5.
• S wave is large in V1 and larger in V2. It gradually becomes smaller from V 3 to
V6.
• T WAVE
•
‘T’ wave is due to the repolarization of ventricle.
•
Duration: 0.2 second
• Amplitude: 0.3 mV
Morphology: positive in leads I, II ,V5, V6 and inverted in lead aVR.

• U’ wave:
 Intervals and segments of ECG

• P-R interval is the interval between the onset of ‘P’ wave and
onset of ‘Q’ wave.
• It shows the duration of conduction of the impulses from the SA
node to ventricles through atrial muscle and AV node.
• Duration: varies between 0.12 and 0.2 second.
• If it is more than 0.2 second, it is called the AV nodal delay.

• Q-T’ INTERVAL
‘Q-T’ interval is the interval between the onset of ‘Q’ wave and
the end of ‘T’ wave.

• Q-T interval indicates the ventricular depolarization

and repolarization.
• S-T’ SEGMENT
‘S-T’ segment is the time interval between the end of ‘S’ wave and
the onset of ‘T’ wave. It is an isoelectric
period.
J Point
• The point where ‘S-T’ segment starts is called ‘J’ point.
It is the junction between the QRS complex and ‘S-T’ segment.

• R-R’ INTERVAL
‘R-R’ interval is the time interval between two consecutive ‘R’
waves
• It signifies the duration of one cardiac cycle.
• Duration
Normal duration of ‘R-R’ interval is 0.8 second
 Electrocardiographic leads
• Three Standard Bipolar Limb Lead
• Shows electrical connections between the patient’s limbs and the
electrocardiograph.
• Record voltage b/n two electrodes (leads) placed on the wrists
and legs.
Lead I= LA-RA, electric potential difference b/n Lft arm & Rt arm
Lead II =LL-RA, electric potential difference b/n Lft leg & Rt arm
Lead III = LL-LA, electric potential difference b/n Lft arm & Lft
leg.
Each lead shows waves of depolarization and
repolarization:
Einthoven’s law: when the ECGs are recorded simultaneously with
the three limb leads, Lead II = Lead I+ Lead III.
 Unipolar leads
• One electrode is active electrode and the other one is an
indifferent electrode.
• Active electrode is positive and the indifferent electrode
is serving as a composite negative electrode.
• Unipolar leads are of two types: Unipolar limb leads and
chest leads.
• Precordial Leads are Unipolar leads labeled as V1, V2, V3,
V4, V5, and V6.
• One electrode is connected to the positive terminal of the
Electrocardiograph and the negative electrode (indifferent
electrode) is connected through equal electrical
resistances to the right arm, left arm, and left leg.
 Unipolar Limb leads
• Are augmented leads
• Voltage is recorded b/n a single “exploratory electrode” placed
on the body and an electrode that is built into the
electrocardiograph and maintained at zero potential (ground).

• In this system, two of the limbs are connected through electrical

resistances to the negative (indifferent) terminal of the
electrocardiograph and the 3rd limb is connected to the positive
terminal.

• When positive terminal is placed on right arm, the lead is

designated as aVR; when on the left arm aVL, and when on left
leg, aVF.
 Application of ECG

1. Anatomical orientation of the heart

2. Heart rate determination

3. Relative size of heart chambers

4. Disturbances of rhythm and conduction

5. Myocardial infarction