ECG_basic

Aija Maca
 ECG

▪ ECG - The graphic record of the electrical changes in

myocardium via electrodes placed on the limbs and chest
wall
Electrical System of the heart
Conduction speed:
➢ Atrium – 1 m/sec
➢ AV node - 0,5 m/sec
➢ Purkinje – 4 m/sec
fibres
▪ “Fast response” cells

Myocytes at the atrium, ventricle,

Hisa – Purkinje system`s cells
 Action potential

Phase 0 - Rapid depolarisation

Phase 1 – Early rapid repolarization
Phase 2 – Plateau
Phase 3 – Final rapid repolarization
Phase 4 – Resting membrane potential
RELATIONSHIP OF INTRACELLULAR
POTENTIAL TO SURFACE ECG
▪ “Fast response” cells “Slow response” cells

Sinus node; AV node

Myocytes at the atrium, ventricle, Hisa – Purkinje system`s cells, atrium
Hisa – Purkinje system`s cells Spontaneous diastolic
depolarization– automatism!!!!
 Refractory period
▪ Refractory period – the time period when the cell`s membran is
unresponsive to the new stimuli – new action potential can`nt be
induced

▪ Absolute refractory period - AP 2 phase (plato), begining of the 3th

phase – Na channels are inactiveted – new action potential
ABSOLUTELY can`be initiated

▪ Relative refractory period– AP 3 phase, initiation of the new AP is

inhibited , but not immpossible.
Refractory period
 ECG parameters
Voltage

Time
0.2 sec or
200 msec

0.1 sec or
100 msec
 ECG
▪ The direction of the deflection on the ECG depends on
whether the electrical impulse is travelling towards or away
from a detecting electrode

✓ An electrical impulse travelling directly towards the electrode produces

an upright (“positive”) deflection relative to the isoelectric baseline

✓ An electrical impulse moving directly away from an electrode produces a

downward (“negative”) deflection relative to the baseline
 The direction of the deflection on the ECG depends
on whether the electrical impulse is travelling towards
or away from a detecting electrode
Positive and negative deflections ECG

Amplitude of the QRS complex

is total sum of amplitude of the
all positive and negative
deflections ( waves)
Standart leads – bipolar leads
Localisation of electrodes
➢ Red – right arm

➢ Yelow – left arm

➢ Green – lef foot

➢ Black – right foot

Standart leads
➢ Right arm – left arm – I lead

➢ Right arm – left foot – II lead

➢ Left arm – left foot – III lead

 Augmented leads from the limbs

➢ Active electrode is placed on limb

➢ Pasive electrode – both others limb`s electrodes
Precordial s. Chest leads
Additional chest leads
 ECG
▪ The six chest leads (V1
– V6) “view” the heart
in the horizontal plane

▪ The information from

the limb electrodes is
combined to produce
the six limb leads ( I, II,
III, aVR, aVL, aVF) –
“view” the heart in the
vertical plane
 Anatomical relations of leads in a standart 12
leads ECG

II, III, aVF Inferior surface of the

heart
V1 – V4 Anterior surface of the
heart
I, aVL, V5, V6 Lateral surface
V1 and aVR Right atrium and cavity of
left ventricle
 The basic elements of the normal
ECG
✓ P-wave
✓ PR(Q)-segment
✓ PR(Q)-interval
✓ QRS- complex
✓ ST-segment
✓ T-wave
✓ U-wave
✓ QT-interval
 P wave
▪ P wave reflects depolarisation of the atria
▪ The atria are anatomically two distinct chambers,
ellectrically they acts as one

▪ Norma: amplitude < 0,25 mV ( 2,5 mm)

duration ≤ 110 ms
110 ms
 I
aVR
aVL

II III
The wave of
depolarisation
is directed inferiorly and
towards the left

P waves tends be positive in leads I, II and

aVF negatives in aVR

II, V1 leads – P waves are most prominently

seen in case of sinus rhythm
P wave
 P wave

▪ P wave in V1 – often biphasic

▪ Early right atrial forces are directed anteriorly - giving rise to
an initial positive deflection
▪ These are followed by left atrial forces traveling posteriorly -
later negative deflection

▪ Normal P wave can be slight notch – result from slight

asynchrony between depolarisation of the right and left
atrium ( N < 40 ms)
P wave

✓ P wave is positive in I; II; III; aVF, V3-V6 and

negative in aVR
✓ Duration ≤110 ms
✓ P wave in V1 often is biphasic with small negative
deflection
✓ Amplitude less than 2,5 mm in II lead and <1,5
mm V1
✓ P wave can be slight notch with distance between
peaks < 20 (40) ms
Conduction through the atrioventriculare node
 PR or PQ interval
▪ PR (Q) interval is the time between the onset of atrial
depolarisation and the onset of ventricular depolarisation

▪ The AV node slows impulse conduction, allowing time for the

atria to contract and blood to be pumped from the atria to the
ventricles prior to ventricular contraction.

▪ Norma : 120 – 200 ms

Ventricular depolarisation – QRS complex
 QRS complex

Norma :
duration < 100 ms

Nomenclature in QRS complex:

Q wave - Any initial negative deflection

R wave - Any positive deflection
S wave – Any negative deflection after an R wave
Morphology of QRS complex
Klīniskā elektrokardioloģija, A. Kalvelis; 2008
 Norma
Trasitional zone
V3 lead
 I
aVR
aVL

II III

aVF
Small non-pathological Q waves I, aVL, V5-V6

Isolated Q wave in V1 –normal finding

 Non-pathological and pathological Q wave

Non-pathological Q wave

pathological Q wave
>25-30% R
ST segment – repolarisation plateu phase

42
 ST segment

▪ ST segment – reflects
the period between the
end of depolarisation
and the begining of
repolarisation

▪ ST segment should be
at baseline, fairly flat
The assessment of the ST segment
T wave – rapid repolarisation phase

45
T – wave

Normal T-wave :
➢ asymetric
➢ positive I, II, V3 – V6
➢ negative aVR
➢ Other leads – variable

Amplitude of the T wave:

➢ 0,5 – 5,0 mm standart leads
➢ 1,0 – 10,0 mm precordial leads
 QT interval

▪ QT interval represents the total time

taken for depolarisation and
repolarisation of the ventricles

▪ In general QT = 350 – 450 ms

▪ The duration depends on heart rate

▪ Bazett formula:
QTC = QT / √ RR
 U wave
▪ The U wave is a small
deflection that follows the T
wave

▪ It is generally upright except

in the aVR lead

▪ U waves results from

repolarisation of middle
myocardial cells

▪ Manu ECG has not U wave -

it may be found in athletes
and are associated with
hypokalaemia and
hypercalcaemia.
Cardiac axis
 Cardiac axis
▪ Cardiac axis reflects mean direction of the wave of
ventricular depolarisation in the vertical plane

▪ Normal range is between - 30° and + 90°

▪ An axis lying beyond - 30° is termed left axis deviation

▪ An axis > + 90° is termed right axis deviation

The assessment of the cardiac axis according to
standard leads
± 0°
Table for Cardiac axis assessment
 (+90) – (-30) Less than (-30) – (-90) >(-90) – (-180)
More than + 90

I is negative, II and III BOATH No positive QRS

at least one of the II or III are positive Are NEGATIVE I; II; III
The assessment of the cardiac axis according to standard leads

▪ The cardiac axis is assessed at the ventricles (QRS complex) and in frontal plane
(standard and augmented leads)

The cardiac axis assessment according to standard leads (I, II, III)
1. Isoelectric (biphasic) complex (R=S/Q) in the one of the standard leads
Cardiac axis is perpendicular to that lead!

▪ If the QRS is positive, the cardiac axis is going in the same direction as the
axis of this lead.
▪ If the QRS is negative, the cardiac axis is going to the opposite direction of this
lead.
Isoelectric (biphasic) complex

The QRS complex is NEGATIVE at the III lead,

Axis is going to the OPPOSITE direction (to”minus”)

Perpendicular axis to II lead

Cardiac axis!!! - 30

I
The QRS complex is POSITIVE at the I lead,
Axis is going in the same direction
as the lead axis

III II
The assessment of the cardiac axis according to standard leads

▪ The cardiac axis is assessed at the ventricles (QRS complex) and in frontal
plane (standard and augmented leads)

The cardiac axis assessment according to standard leads (I, II, III)
2. Isoelectric (biphasic) complex (R=S/Q) IS NOT in the one of the standard leads

Choose the two leads from three with the largest amplitudes ( it doesn`t matter positive or
negative)

Cardiac axis is between the axis of those two leads.

▪ If the QRS is positive, the cardiac axis is going in the same direction as the axis of this
lead.

▪ If the QRS is negative, the cardiac axis is going to the opposite direction of this lead.
Two leads with the largest amplitude

The QRS complex is POSITIVE at the I lead,

Axis is going to the same direction
as the lead axis

I
Cardiac axis!!! ~ (+30)

III II
The QRS complex is POSITIVE at the II lead,
Axis is going in the same direction
as the lead axis
Two leads with the largest amplitude

The QRS complex is NEGATIVE at the I lead,

Axis is going to the OPPOSITE direction I

Cardiac axis!!! ~ (+150)

III II
The QRS complex is POSITIVE at the III lead,
Axis is going in the same direction
as the lead axis
Two leads with the largest amplitude

The QRS complex is NEGATIVE at the III lead,

Axis is going to the OPPOSITE direction (to”minus”)

Cardiac axis!!! ~ ( - 45)*

I
The QRS complex is POSITIVE at the I lead,
Axis is going in the same direction
as the lead axis

III II
*The cardiac axis is closer to the lead
with the largest amplitude
 Cardiac axis
Normal axis Right axis Left axis
deviation deviation
Lead I positive negative positive
Lead II positive positive or
negative negative
Lead III positive or
negative positive negative
 TERMINOLOGY

“NORMAL SINUS RHYTHM”

AND
“SINUS RHYTHM”

Ary L. Goldberger MD, FACC, ... Alexei Shvilkin MD, PhD,

Goldberger's Clinical Electrocardiography (Ninth Edition), 2018
 “Normal sinus rhythm”

▪ “If you state that the rhythm is “normal sinus” and do not mention any AV
node conduction abnormalities, listeners will assume that each P wave is
followed by a QRS complex and vice versa. The more technical and
physiologically unambiguous way of stating this finding is to say: “Sinus
rhythm with 1:1 AV conduction.”

Ary L. Goldberger MD, FACC, ... Alexei Shvilkin MD, PhD,

Goldberger's Clinical Electrocardiography (Ninth Edition), 2018

▪ Normal sinus rhythm = positive P wave in II, and negative aVR with normal
AV and intraventricular conduction.

▪ Example: 2nd degree AV block 2:1 IS NOT Normal sinus rhythm

 “Sinus rhythm”

▪ ”Strictly speaking, when you diagnose “sinus rhythm,” you are only
describing the physiologic situation in which the sinus node is generating
P waves (upright in lead II, inverted in aVR). But this term, by itself, says
nothing about AV conduction. Sinus rhythm (i.e., activation of the atria
from the SA node) can occur not only with normal (1:1) AV conduction
but with any degree of AV heart block (including second- or third-
degree), or even with ventricular tachycardia (a type of AV dissociation).
In the most extreme case, a patient can have an intact sinus node
consistently firing off impulses in the absence of any ventricular
activation, leading to ventricular asystole and cardiac arr

Ary L. Goldberger MD, FACC, ... Alexei Shvilkin MD, PhD,

Goldberger's Clinical Electrocardiography (Ninth Edition), 2018

▪ Example: Sinus rhythm with 3th degree AV block.

 Heart frequency

▪ 60 / R-R interval (seconds)

▪ 60/ 18 ( 1 mm small boxes) x 0,04 s = 60/0,72 = 83

 Heart frequency

▪ Aproximatelly: number of R waves in 15 (5mm) large boxes) x 20

▪ 4 x 20 = 80
Heart frequency
Heart frequency
ECG_basic

Aija Maca