Electrocardiogram

(ECG)
DR ATEEQA YOUNIS
LECTURER FUCP
Impulse Conduction through
the Heart

225msec
0.22 sec
Transmission of the cardiac impulse through the heart,
showing the time of appearance (in fractions of a second
after initial appearance at the sinoatrial node) in different
parts of the heart.
 Electrocardiogram (ECG)
 Graphic record of summated electrical activity of

heart obtained by electrodes placed on body surface.

 Represents:
 Recording of part of electrical activity induced by
cardiac impulse that reaches body surface.
 Electrocardiogram 5

 Method developed by Wilhelm Einthoven

 Dutch “Elektrokardiogram” (EKG)
 Now usually “ECG.”

 Records electrical events in heart.

 Variations in electrical potential radiate from heart; detectable at
wrists, ankles.
Electrocardiogram (ECG)--
contd

 Recording of overall spread of activity

throughout heart during depolarization
and repolarization.
 Not a recording of a single action
potential in a single cell at a single point
in time (syncytium).
 Comparisons in voltage detected by
electrodes at two different points on
body surface.
 CARDIAC ACTION
POTENTIAL VS ECG?
Action potential from a
ventricular muscle fiber
during normal cardiac
function, showing rapid
depolarization and then
repolarization occurring
slowly during the plateau
stage but rapidly toward the
end.
 11

 Action Potential records voltage inside the

cell (ion changes)

 ECG records voltage out side the cells.

(conduction)
Electrocardiogram
Electrocardiogram

 Record of electrical
events in the
myocardium can be
correlated with
mechanical events

*AV nodal delay:

It ensures that the
atria have ejected
their blood into the
ventricles first before
the ventricles
contract.
 An interval in an ECG is a
A segment in an
duration of time that includes
electrocardiogram is the region
one segment and one or more
between two waves. PR segment
waves. The PR (or PQ) interval
begins at the end of the P wave
starts at the start of the P wave
and ends at the onset of the
and ends at the start of the
QRS complex.
QRS.
REPOLARIZATION OF PURKINJI FIBRES
PROMINENT IN HYPOKALEMIA
 Electrocardiogram

P wave: QRS complex:

depolarization of ventricular T wave:
atrial myocardium. depolarization

Signals onset of
Signals onset of atrial repolarization of
ventricular
contraction ventricles
contraction.
 PR Extends from start of atrial depolarization
interval (P wave) to start of ventricular
: 0.16 depolarization (QRS complex).P
sec WAVE+PR SEGMENT

Atria contract and begin to relax: includes

conduction of cardiac impulse through AV
node.

Can indicate damage to conducting

pathway or AV node if greater than 0.20
sec (200 msec)
 Q-T interval: QRS + ST
segment +T wave

Can be lengthened by
time required for ventricles
electrolyte disturbances,
to undergo a single cycle of
conduction problems,
depolarization and
coronary ischemia,
repolarization.
myocardial damage
ECG Graph Paper
Calibration
 ECG Graph Paper Calibration 27

Vertical lines

10 small lines in
measurement of Or I small
2 large boxes = 1
voltage square= 0.1 mV
mV
 Horizontal lines

Measurement of time Speed: 25mm/sec

I small square=
0.04 sec

What will be the time of 5 small boxes????

0.04*5=0.1
 10 boxes= 1 mV/ 10mm

0.1mv
DURATION / VOLTAGE
0.1 mv RR interval
R
ST Segment TP Segment

T
P
Voltage

Q
S J Point

PR interval
QT interval

Time 0.04 Sec 0.2 Sec

• PR interval 0.12 – 0.20 • QT interval 0.4 – 0.43 sec

sec • RR interval 0.6 – 1.0
• QRS duration 0.08 – 0.10 sec sec 32
VOLTAGE 33

 P wave voltage= 0.1- 0.3 millivolts

Q wave = 1.0 to 1.5 millivolts
R wave= I mV
S wave= 0.4mV
 T wave= 0.2- 0.3 millivolts
Calculation of heart rate
 36

 Calculation of heart rate

1. 60/time in sec between 2 consecutive R waves
2. 300/no of large squares between 2 consecutive R waves
3. 1500/no of small squares between 2 consecutive R waves
4. 6 second strip
1. Number of QRS complexes X 10

7 x 10 =70 bpm
•There are 300 large squares per
minute.
•If the rhythm is regular count the
number of large squares between two
QRS complexes and divide it into
300.

2. 300/4.2 =71 bpm

3. 300-150-100-75-60 method
4. 1500 method
Heart Excitation Related to ECG
P wave: atrial
START depolarization

The end
R PQ or PR segment:
conduction through
AV node and A-V
P T bundle

QS P

Atria contract.

T wave:
ventricular ELECTRICAL
Repolarization
Repolarization R EVENTS
OF THE
CARDIAC CYCLE
P T

QS

P Q wave

Q
ST segment
R

R wave
P R

QS
P
Ventricles contract. R
Q

P S wave

QS
CLINICAL USE OF ECG 42

 Heart rate
 Rhythm
 Infarction
 Hypertrophy
 Electrolyte imbalance
 Drug toxicity
 EKG Problems

Large QRS – caused by hypertrophy

Small QRS – reduced heart muscle mass

Small T –ischemia

Long P-R interval – damage to conducting pathways

Long Q-T interval – conduction problems, myocardial damage,

ischemia, congenital defect
ECG LEADS
Leads 48

 Electrodes placed on the body are assigned by the ECG

machine as being positive or negative.

 A lead is made up of at least two electrodes in which one

electrode is the positive reference electrode, and the other is
the negative reference electrode.
1. Standard Bipolar limb leads

I

 II

 III
 Comparing voltage differences
between each of the three ECG
electrodes
 By convention, the left shoulder is
designated the positive pole of lead
I
 whereas the foot is designated the
positive pole of leads II and III.
LEADS:

 Lead I records voltage differences between

the right and left shoulders
 Lead II compares the right shoulder and
the left foot
 Lead III compares the left shoulder and
left foot.
 Einthoven’s triangle
52

 The three standard

bipolar limb leads
make a “triangle”
around the heart in
the frontal plane.
 Einthoven’s Law

 If the electrical potentials of any two of the three bipolar

limb leads are known at any given instant, the third one can
be determined mathematically by simply summing the first
two

 e.g. lead II = I + III

This is known as Einthoven’s law
 2. Augmented (Unipolar Limb) Leads

 aVR  Three unipolar leads

compare voltage
 aVL differences between skin
electrodes and a common

 aVF reference point (central

terminal) that is held close

to zero.
55
Leads aVL, aVR, and aVF
measure voltage differences
between this point and the left
shoulder, right shoulder, and foot,
respectively.
The skin electrodes are
considered to be the positive pole
in each case
 3. Precordial leads
 Unipolar leads
Compare voltage differences
between the common reference point
and six additional skin electrodes

placed in a line directly above the heart in the horizontal plane

(V1 through V6)
Axes of chest leads in frontal plane/deflections
Anatomical relations of leads in a standard 12 lead
electrocardiogram

•II, III, and aVF: inferior surface of the heart

•V1 to V4: anterior surface

•I, aVL, V5, and V6: lateral surface

•V1 and aVR: right atrium and cavity of left ventricle

 65

Cardiac Arrhythmias
 Causes Of The Cardiac
Arrhythmias
 Abnormal rhythmicity of the pacemaker.
 Abnormal pacemaker
 Blocks in normal conduction pathway of cardiac impulse
 Abnormal pathways of cardiac impulse
 Spontaneous generation of ectopic impulses in almost any part of the heart.
 1. Normal Sinus Rhythm (NSR) 67

 Rhythm generated by SA node at a rate of 60 to 100 beats per minute with P–

QRS–T waves at regular intervals.

Normal Sinus Rhythm
 2. ACUTE MYOCARDIAL INFARCTION
 The hallmark of acute myocardial infarction is elevation of the ST
segments in the chest leads overlying the area of infarction
 3. Sinus Tachycardia 69
 Normal sinus rhythm with heart rate more than 100 beats per minute
 Exercise, emotions, fever, hyperthyroidism, shock, heart failure etc
 4. SINUS BRADYCARDIA 70
 Normal sinus rhythm with heart rate less than 60 beats per minute
 Sleep, Athletes, drugs (beta blockers), etc
5. Heart Blocks 71

1. Intra-atrial blocks

2. Atrioventricular blocks

3. Intraventricular blocks
 1. Intra-atrial blocks 72

 Sinus arrest (sick sinus syndrome)

 SA node fails to generate an impulse

 Sino-atrial exit block

 impulses discharged in the sinoatrial node are either not conducted to
the atria or are so with a delay.
Intra-atrial blocks 74

 A complete cycle (P-QRS-T) is missed → missed beat

 SA node resumes pacing
2. Atrioventricular blocks 75
 Incomplete heart blocks
 First degree heart block:
PR interval more than 0.2 seconds

Normal
ECG

First
degree
heart
block
Atrioventricular blocks 76
 Incomplete heart blocks

Second Degree Heart Block

 i) Gradual lengthening of PR interval until
blocking the impulse “ dropped beat" –
Wenckebach phenomenon or Mobitz I
 ii) Intermittent conduction of impulse from atria
to ventricles – Mobitz II
 77
Wenckebach phenomenon/ Mobitz I

Mobitz II phenomenon
Atrioventricular blocks 78
 Complete heart block
Third degree heart block
Total blockade of impulse conduction from atria
to ventricles
Atrioventricular dissociation

Atria pace at their own rhythm

Stokes-Adams Syndrome
80
3. Intraventricular blocks 81

 Bundle branch blocks

 Right bundle Branch block
 Left bundle branch block

 Electrical alternans
 Incomplete intraventricular block in
peripheral purkinje system
LBBB
RBBB
Escape beats 84
An escape beat is a heart beat arising from an
ectopic focus in the atria, the AV junction, or
the ventricles when the sinus node fails in its
role as a pacemaker .

 Atrial escape beat

 Atrial ectopic focus (60-80 beats/min)
 Junctional escape beat
 Junction ectopic focus (40-60 beats/min)
 Ventricular escape beat
 Ventricular ectopic focus (15-40 beats/min)
6.Wolff–Parkinson-White Syndrome
 An accessory pathway between atria and ventricles
 Shortened PR interval, widened QRS complex and
slurred upstroke of the R wave (delta wave)
 7. Premature Contractions 87
 A contraction that appears before its expected time
from an irritable ectopic focus
 Also called extrasystole, premature beat, or ectopic
beat

 Premature atrial contraction

 Premature junctional contraction
 Premature ventricle contraction (PVC)
Premature Atrial contraction 88

Premature Junctional Contraction

 90
NORMAL

abnormally wide QRS and bizarre looking T wave

Causes of Premature Contractions
92

Irritable ectopic foci

1) local areas of ischemia

2) small calcified plaques at different points in the heart

3) toxic irritation of the A-V node, Purkinje system, or

myocardium caused by drugs, nicotine, or caffeine.

 Occasional discharge leads to Premature

contractions

 Repetitive discharge at rate higher than SA node

leads to Paroxysmal tachycardia, Flutter or

Fibrillation

 Compensatory Pause
Specific Effects In The Electrocardiogram
Caused By Premature Ventricular
Contractions (PVCs)

1. The QRS complex is usually considerably prolonged

The impulse is conducted mainly through slowly
conducting muscle of the ventricles rather than
through the purkinje system.
2. The QRS complex has a high voltage.

When a PVC occurs, the impulse almost always travels

in only one direction, and one entire side or end of the
ventricles is depolarized ahead of the other; this causes
large electrical potentials in ECG.
3. After almost all PVCs, the T wave has an electrical

potential polarity exactly opposite to that of the

QRS complex
 8. TACHYARRHYTHMIAS 97

 Paroxysmal tachycardia
 Heart rate from 150-250 beats per minute
 Flutter
 Heart rate from 250-350 beats per minute
 Fibrillation
 Heart rate from 350-450 beats per minute

97
 Tachyarrhythmias 98
 Paroxysmal tachycardia
 Atrial
Supra-ventricular tachycardia
 Junctional
 Ventricular
 Flutter
 Atrial
 Ventricular
 Fibrillation
 Atrial
 Ventricular
 Ventricular Tachycardia

Supra-ventricular tachycardia

QRS
NARROW
 FLUTTER

Atrial Flutter-240-400 beats/min

Saw tooth appearance

Ventricular Flutter-250-350 beats/min

Ventricular Flutter-250-350 beats/min
 Atrial Fibrillation 350-650 beats/min

Ventricular Fibrillation 300-600 beats/min

 Tachyarrhythmias 10
5
 Mechanisms
 Re-entry or circus movement
 Irritable multiple ectopic foci

105