Introduction to Electrocardiography

Few Terms:
Myocardium - the walls of the chamber of the heart which contain the musculature that acts during the

pumping of blood

ESlecfrocardiogram (ECG) -agraphic recording or display of the time variant voltages produced by the
myocardium during the cardiac cycle.
Electrocardiograph-an instrumentation system used to obtain and record the electrocardiogram.
Arrhythmia - an alteration in rhythm of the heartbeat either in time or force.

Heart Block - a delay or interference of the conduction mechanism whereby impulses do not go
through all or a major part of the myocardium.

A BRIEF HISTORY OF ECG:

In 1901, Dutch physician Willem Einthoven developed a "string galvanometer that could record the
electrical activity of the heart. Although it was not the first such recorder, it was a breakthrough in that it
was accurate enough to duplicate the results on the same patient. Einthoven's work established a
standard configuration for recording the ECG and won him the Nobel Prize in 1924. Since then, ECG
has become a powerful tool in diagnosing disorders of the heart.

BASIC UNDERSTANDING OF HEART ACTIVITY:

The main function of the heart is to pump blood through two circuits:

1. Puimonary circuit through the lungs to oxygenate the blood and remove carbon dioxide, and
2. Systemiccireuit; to deliver oxygen and nutrients to tissues and remove carbon dioxide.
Because the heart moves blood through two separate circuits, it is sometimes described as a dual pump.

In order to beat, the heart needs three types of cells:

1. Rhvthmgenerators, which produce an electrical signal (SA node or normal pacemaker)
2. Conductors to spread the pacemaker signal, and

3. Contractile cells (myocardium) to mechanically pump blood.

The Electrical and Mechanical Sequence of a Heartbeat:

The heart has specialized pacemaker cells that start the electrical sequence of depolarization and
repolarization. This property of cardiac tissue is called inherent rhythmicity or automaticity.
 The electrical
signal is generated by the sinoatrial node
muscle via (SA node) and spreads to the ventricular
particular conducting pathways: intemodal
atrioventricular node (AV node,) the pathways and atrial fiberS, the
fibers. (Refer the bundl His, the right and left bundle branches, and
of
figure for bioelectric potential conduction Purkinje
When the electrical system in heart)
signal of a depolarization reaches the
mechanical event called contractile cells, they contract-a
systole.
When the
repolarization signal reaches the myocardial cells,
diastole they relax-a mechanical event called
Thus, the electrical signals cause the
mechanical pumping action of the
always follow the electrical events. heart; mechanical events
The SAnode is the nomal
pacemaker of the heart, initiating each electrical andd mechanical
When the SA node
depolarizes, the electrical stimulus spreads cycle.
muscle to contract. Thus, the SA
node depolarization is followed
through atrial muscle causing the
The SA node by atrial contraction.
impulse also spreads to the
(The wave of depolarization does not atrioventricular node (AV node) via the internodal fibers.
spread to the ventricles right away because there is
nonconducting tissue separating the atria and ventricles.)
The electrical signal is
delayed in the AV node for approximately 0.20 seconds
contract, and then the signal is when the atria
relayed to the ventricles via the bundle
branches, and Purkinje of His, right and left bundle
fibers.
The Purkinje fibers relay the electrical impulse directly to ventricular
ventricles to contract (ventricular muscle, stimulating the
systole). During ventricular systole, ventricles
and then enter a period of diastole. begin to repolarize
The Heart Rate

Although the heart generates its own beat, the heart rate
contraction of the heart are modified by the (beats per minute or BPM) and strength of
nervous system.
sympathetic and
parasympathetic divisions of the autonomic
The sympathetic division increases automaticity and
heart rate. It also increases excitability of the SA node, thereby increasing
conductivity electrical impulses through the atrioventricular conduction
of
system and increases the force of atrioventricular contraction.
inhalation. Sympathetic influence increases during
The parasympathetic division decreases automaticity and
excitability of the SA node,
thereby
decreasing heart rate. It also decreases conductivity of electrical
conduction system and decreases the force of atrioventricular
impulses
through the atrioventricular
contraction. Parasympathetic influence
increases during exhalation.
 ne average resting heart rate for adults is between 60-80 beats/min. (Average 70 bpm for males and 75

bpm for females.)

A slower rate is called
bradycardia (slow heart).
A higher rate is called tachycardia (fast heart).

THE ECG ACTIVITY

"echoes" of
S
as n e
activity of the pacemaker is communicated to the cardiac muscle,
electrical
the depolarization and repolarization of the heart are sent through the rest of the body.
By placing a pair of very sensitive receivers (electrodes) on other parts of the body, the echoes or

the heart's electrical activity can be detected.

The record of the electrical signal is called an electrocardiogram (ECG).
W e can infer the heart's mechanical activity from the ECG.
Electrical activityvariesthrough the ECG.
T h e ECG represents electrical events of the cardiac cycle whereas Ventricular Systole and
Ventricular Diastole represent mechanical events (contraction and relaxation of cardiac muscle,
passive opening and closing of intracardiac valves, etc.).
Electrical events occur quickly, mechanical events occur slowly. Generally, mechanical events
follow the electrical events that initiate them.
Thus, the beginning of ventricular diastole is preceded by the beginning of ventricular
depolarization.
In fact, in a normal resting Lead II, ventricular repolarization normally begins before the completion
of ventricular systole in the same cardiac cycle.
Because the ECG reflects the electrical activity, it is a useful "picture" of heart activity. If there are
interruptions of the electrical signal generation or trasmission, the ECG changes. These changes
can be useful in diagnosing changes within the heart.

COMPONENTS OF THE ECG, MECHANICAL AND ELECTRICAL CYCLES

The electrical events of the heart (ECG) are usually recorded as a pattem ofa baseline (isoelectric ine,)
broken by aP wave, a QRS complex, and a T wave. In addition to the wave components ofthe ECG,
there are intervals and segments
and
The isoelectric line is a point of departure of the electrical activity of depolarizations
not detect
repolarizations of the cardiac cycles and indicates periods when the ECG electrodes did
electrical activity.
 An interval is a time measurement that includes waves and/or complexes.

A Segment is a time measurement that does not include waves and/or complexes.

Venarioulr lestale-

rnerval-
-RRInterva
Cardiac
Mechanical Events of the
ECG (Lead I) and Electrical and
Figure 1: Components of the BIOPAC Systems, Inc.
Cycle

Lead II Values
Table: Components of the ECG and Typical
Duration Amplitudes

ECG Measurement Area

Represents .. (Seconds) (mV)
COMPONENT Depolarization of the right and left
P Begin and end on
isoelectric line atria 0.07-0.18 <0.25
(baseline); normally
limb
upright in standard
leads. Depolarization of the right
and left
QRS Begin and end on ventricles. Atrial repolarization
is
isoelectric line but the
Complex also part of this segment,
(baseline) from start of electrical signal for atrial
0.06-0.12 0.10-1.50
Qwave toend of S the
wave.
repolarization is masked by
larger QRS complex.

and left
Repolarization of the right
Begin and end on ventricles.
0.10-0.25 <0.50
isoelectric line
(baseline) Time from the onset of atrial
to
From start of P wave
0.12-0.20
P-R
start of QRS complex. depolarization to the onset of
ventricular depolarization.
From start of QRS Ttime from onset of ventricular
Q-T T depolarization to the end of
complex to end of ventricular repolarization. It 0.32-0.36
wave.
represents the refractory period of
the ventricles.
 ECG
Measurement Area Duration Amplitudes
COMPONENT Represents.
(Seconds) (m)_
R-R From peak ofR wave to Time betweentwo successive
peak of succeeding R ventricular depolarizations. 0.80
wave.
P-R From end of P wave to Time of impulse conduction from
start of QRS complex. the AV node to the ventricular 0.02-0.10 X

myocardium.
S-T Between end of S wave Period of time representing the
and start of T wave. early part of ventricular
repolarization during which <0.20
ventricles are more or less
uniformly excited.
T-P |From end of T wave toTimefrom the end of ventricular
start of successive P repolarization to the onset of atrial 0.0-0.40
wave. depolarization.

FEW POINTS ON ECG

I n healthy individuals the electrocardiogram remains reasonably constant, even though the heart rate
changes with the demands of the body.
I t should be noted that the position of the heart within the thoracic region of the body, as well as the
position of the body itself (whether erect or recumbent), influences the electrical axis" of the
heart.
The electrical axis (which parallels the anatomical axis) is defined as the line along which the
greatest electromotive force is developed at a given instant during the cardiac cycle. The electrical
axis shifts continually through a repeatable pattern during every cardiac cycle.
For his diagnosis, a cardiologist would typically look first at the heart rate. The normal value lies in
the range of 60 to 100 beats per minute. A slower rate than this is called bradycardia (slow heart)
and a higher rate, tachycardia (fastheart)
He would then seeif the cycles are evenly spaced. If not, an arrhythmia may be indicated.
. I f the P-R interval is greater than 0.2 second, it can suggest blockage ofthe AV node.
I f one or more of the basic features of the ECG should be missing, a heart block of some sort might
be indicated.
The electrocardiograph was the first electrical device to find widespread use in medical diagnostics,
and it still remains the most important tool for the diagnosis of cardiac disorders. Although it
provides invaluable diagnostic information, especially in the case of ahythmias and myocardial
infarction, certain disorders-for instance, those involving the heart valves-cannot be diagnosed
from the electrocardiogram. Other diagnostic techniques, however, such as angiography and
echocardiography can provide the information not available in the electrocardiogram.
 Introdaction to Electrocardiography-2
Electrodes:
To record an
electrocardiogram,
paica. The clectrodes a number
are connected
of
electrodes, usually five, are affixed o the
by the same number of electrical body the
Wres and, in a to the ECG machine of
more
gecneral sense, the wires.
The
placemant of the electrodes, as wellelectrodes to which
they are connected are usually called
the color code used to
These
kads.
the figre below. as
identify each electrode, is shown in

Figare: Abbreviations and colour codes used for ECG electrodes.

The particular bipolar arrangement of two electrodes (one positive, one negative) with
electrode (the grownd) is called a lead. The elecarode respect to a third
positions for the diferent leads have been
sandardized

The dominant ECG component in any normal standard lead record is the
QRS complex. Usually, in a
Lead II recording the Q and S waves are small and
negative and the R wave is large and as positive
discussed earlier. However, it is mportant to note many factors, normal and abnormal, detemine the
duration form, rate, and rhythm of the QRS complex. Nomal factors include body size (BSA) and
distribution of body fai, heart size (ventricular mass.) position of the keart in the chest relative to lead
ocations, metabolic rae, and others.
 Depending on lcad configuration, most commonly threc to six adhesive skin electrodes art alached to
Uhe
participant's wrist and ankles, although in certain applications, electrodes can be appied to the
chestor torso. A lead set
is then attached to the clectrodes and connected to an ECG amplitier, data
Acquisition unit or wireless transmitter or
logger. There are two types of electrodes, resable and
asposabie One has to decide which type of ECG clectrodes best suits his/ her testing envirooment
Whichever type is used, proper preparation and application of clectrodes/ leads is vital for obtaaning
good ECG data

Basic Lead I, IL, and II

Configurations:
The normal electrode
placement for basic Lead I, I, and III configurations is shown below-

Figure: Basic Lead 1, Il, and ll configurations (bipolar limb

leads)

The electrode on the right leg is used for the ground referenc.
The three bipolar limb lead selections first
introduced by Einthoven as sbown in the above
configuration is as follows: figure. The
Lead E Right Anm (RA) Gto Left
Am(LA) (H)
Lead I: RightAm (RA)Go Lef Leg (L)(4)
Lead I : Left Am (LA) to Left
Leg L)(H

In each of these lead

positions, the QRS of a
nomal heart is such that the R wave is
with electrocardiograms from these three basic limb leads, Einthoven
positive. In working
of the cardiac cycle, the frontal postulated that at any given instant
plane representation of the ekectrical axis of the heart is a two
dimensional vector. Further, the ECG measured from any one of the
three basic limb leads is a time
variant single-dimensional component of that vector. Einthoven
also made the
(the origin of the vector) is near the center of an assumption that the heart
Einthoven triangle. This has been shown in the next
equilateral triangle. This triangle, known as the
page.
 8ight Left

Ground
Figure: The Einthoven Triangle.

The sides of the triangle

represent the lines along which the three projections of the ECG vector are
measured. Based on this, Einthoven showed that the instantaneous
voltage measured from any one of the
three limb kad positions is approximately
equal to the algebraic sum of the other two, or that the vector
sum of the
projections on all three lines is equal to zero. For these statements to actually hold true, the
polarity of the ead Il measurement must be reversed. of the three limb leads, lead II produces the
greatest R-wave potential. Thus, when the amplitudes of the three limb leads are measured, the R-wave
amplitude of lead I is cqual to the sum of the R-wave amplitudes of leads I and Ill.

(Augmented) Unipolar limb leads:

This configuration has been introduced by Wilson in 1944. For unipolar leads, the electrocardiogram is
recorded between a single exploratory electrode and the central terminal, which has a
potential
coresponding to the center of the body. This central terminal is obtained by connecting the three active
Finb clectrodes together through resistors of equal size. The potential at the connection point of the
resistors coresponds to the mean or average of the potentials at the three electrodes. In the unipolar limb
leads, one of the limb electrodes is used as an exploratory clectrode as well as contributing to the central
Lerminal. This double use results in an ECG signal that has a very small amplitude. In augmented
unipolar limb lcads, the limb electrode used as an exploratory electrode is not used for the central
 terminal, thereby
increasing the amplitu
appreciably. These leads litude of the ECG signal without changing ts
waveform
are
designated aVR, aVL, and aVF (F as in
toot)

Figure: (Augmented) Unipolar Limb Leads

configuration.
Unipolar Chest Lead
configuration:

Figure: Unipolar Chest Lead configuration

For the unipotar chest leads, a single chest electrode (exploring cledrode) is sequentially placed on cach
of the six predesignated points on the chest. These chest positions are called the precordial unipolar
leads and are designated V, through V These leads are diagrammed in the above figure. All thre active
limb electrodes are used to obtain the central teminal, while a separate chest electrode is used as an
exploratory electrode.

V,:Fourth intercostal spacc, a rightstemal margin.

V2: Fourth intercostal space, at left stemal margin.
V3: Midway between V2 and Va.
V: Fifth intercostal space, at mid-clavicular line.
Vs:Same level as V, on anterior axillary lime.
Vs:Sene leel as V4, on mid-axillary line.
Totl12 led configuration
Iapat Circait of ECG:

Figure Input circuit ofmoderm ECG machine with buffer amplifier, driven right-leg lead and over-
voltage protection
Some of the features of the above ECG machine input circut are -

. To increase the input impedance and thus reduce the effect of variations in electrode impedance,
these instnanents usually include a buffer amplifier for each patient lead. The trasistors in thes
amplificrs are oftcn protected by a nctwork of resistors and neon lamps from overvoltages that may
occur when the clectrocardiograph is used during surgcry in conjunction with high-frequency
devices for cutting and coagulation
.A more severe problem is the protection of the clectrocardiograph from damage during
defibrillation. The votages that may be encountered in this case can reach several thousand volts.
Thus, special measures must be incorporated into the ekectrocardiograph to prevent burmout of
components and provide fast recovery of the trace so as to permit the success of the countershock to
be judged.
Some modem devices do not connect the right eg of the patient to the chassis, but utilize a "drive
the from all other
right leg kad." This involves a summing network to obtain the sum of voBtages
eiectrodes and a driving amplifier, the output of which is connected to the rnght leg of the patient.
The cffect of this arangement is to force the refcrence connection at the right leg of the patient to
assume a voltage cqual to the sum of the voltages at the other kads. This arangement increases the
common-mode rejcction ratio of the overall system and reduces interference. It also has the effect of

reducing the curent fow in theright leg electrode. mcreased concerm for the safety aspect of
abandon the principle of a
eectrical connections to the patient bave caused modem CG designs to
ground reference altogether and use isolated or floating- input amplifiers.
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