ELECTROCARDIOGRAM

(ECG)

Dr Syed Shahid Habib

Professor & Consultant Clinical Neurophysiology
Dept. of Physiology
College of Medicine & KKUH
King Saud University
 OBJECTIVES
At the end of this lecture you should be able to:

• Define ECG & list uses of ECG

• Explain basic ECG principles
• Describe ECG leads and their application
• Recognize ECG waves, Intervals and, segments
• Determine rate and normal heart rhythm
• Have some idea about ECG abnormalities in
common clinical conditions
Einthoven’s original machine weighed 500 pounds and
needed five operators
Modern ECG Machines
ECG is the record of the algebraic sum of electrical activity i.e.
action potentials generated by the heart during cardiac cycle
Monophasic action potentials recorded from a
microelectrode inserted to the inside of a single fibers

The action potentials and ECG are plotted on the same time axis
 ECG PRINCIPLE
When the depolarization wave
spread through heart, electrical
currents pass into the surrounding
tissue (body fluids are good
conductors) and can be recorded
from surface electrodes

Depolarization, is traveling
from left to right

Depolarization completed

Repolarization, is traveling
from left to right

Repolarization completed
 What types of information can we obtain from an ECG?

•Heart rate
•Heart Axis
•Heart Rhythm
•Myopathies
•Carditis
•Chamber Hypertrophy
•Conduction defects
•Myocardial
Ischemia/MI
•Electrolyte
disturbances
•Drug toxicity (eg; digoxin)
 3 waves:
ECG Waveforms (Deflections)
• P- wave
• QRS complex
• T- wave

3 segments:
(isoelectric record only)
•ST segment
•TP segment
•PR segment

3 time intervals:
(include waves only)
•P-R interval
•Q-T interval
•R-R interval
 SEQUENCE OF CARDIAC EXCITATION

Anatomical position of electrical activity with Corresponding electrocardiogram

 ECG Waveforms
P- wave
• Due to atrial depolarization
• P-wave is recorded before onset of atrial systole
• Atrial repolarization occurs at the same time with
ventricular depolarization. But, since ventricular
depolarization wave is giant, it masks the atrial
repolarization wave

QRS complex
• Due to ventricular depolarization T- wave
• Q-wave due to depolarization of interventricular
septum •Due to ventricular
• R-wave due to depolarization of ventricles repolarization
• S-wave due to depolarization of base of the heart •T-wave is recorded
• QRS complex is recorded before the onset of before the onset of
ventricular systole ventricular diastole
Pattern of Excitation of Ventricles to
Produce QRS Complex in ECG
 R-R interval S-T segment
The interval between two successive R- During this segment all
waves. Used to measure Heart rate ventricular muscles are
completely depolarized,.
P-R interval
• P-R interval is the time from the
initial depolarization of atria to
the initial depolarization of
ventricles.
• denotes atrial depolarization &
AV delay.

T-P segment
Time interval from end of ventricular
Q-T interval
Indicates Vent Depolarization
repolarization till next atrial depolarization.
& Repolarizatio
It represents ventricular filling.
 Causes of ECG Waves
ECG Wave Cause Represent
P- wave Atrial Time of electrical impulse from SA node to spread through atrial
depolarization muscle. Duration = 0.08 – 0.1 sec
Precedes atrial contraction by ≈ 0.01 - 0.02 sec

QRS Ventricular Measured from beginning of Q wave till end of S wave.

complex depolarization
Consists of 3 waves:
Q wave: (-ve): Produced by depolarization of interventricular septum.
R wave: (+ve): Produced by depolarization of ventricular wall.
S wave: (-ve): Produced by depolarization of the base of the heart.
Duration ≤ 0.1 sec.
Precedes ventricular contraction by ≈ 0.02
sec. Occurs after P-wave by ≈ 0.12-0.2 sec =
PR interval

T- wave Ventricular Occurs during latter part of systole, before the onset of
repolarization diastole. Ventricular repolarization progresses from apex to the
base of the heart. Duration = 0.27 sec.
Atrial repolarization occurs at the same time with ventricular depolarization. But, since
ventricular depolarization wave is giant, it masks the atrial repolarization wave
14
 CARDIAC VECTORS
Electrical forces can be
represented in the form of
vectors
A vector is an arrow that
points in the direction of
the electrical potential
generated by the
current flow, with the
arrowhead in the positive
direction.
The length of the arrow is
proportional to the voltage
of the potential.
DEPOLARIZATION OF THE ATRIA—THE P WAVE
The area in the atria that also becomes repolarized first is the sinus nodal
region, the area that had originally become depolarized First . Therefore, the
atrial repolarization vector is backward to the vector of depolarization

In a normal ECG, the

atrial T wave appears at
about the same time that
the QRS complex of the
ventricles appears.
Therefore, it is almost
always totally obscured
by the large ventricular
QRS complex
 VECTORS THAT OCCUR AT SUCCESSIVE
INTERVALS DURING DEPOLARIZATION
OF THE VENTRICLES—THE QRS COMPLEX
• When the cardiac impulse enters the ventricles through the
atrioventricular bundle, the first part of the ventricles to
become depolarized is the left endocardial surface of the
septum.

• It spreads through the ventricular muscle to the outside of

the heart

• Q wave is caused by initial depolarization of the left side of

the septum before the right side, which creates a weak
vector from left to right for a fraction of a second before the
usual base-to-apex vector occurs.
 Because the septum and endocardial areas
ELECTROCARDIOGRAM of the ventricular muscle depolarize first, it
DURING VENT seems logical that these areas should
REPOLARIZATION repolarize first as well, but actually it is NOT
THE T WAVE so!!!!!!!!

• The greatest portion of ventricular muscle mass to

repolarize first is the entire outer surface of the ventricles,
especially near the apex of the heart because the septum
and other endocardial areas have a longer period of
contraction than do most of the external surfaces of the
heart so endocardial areas, conversely, normally repolarize
last.
• Therefore, the positive end of the overall ventricular vector
during repolarization is toward the apex of the heart. As a
result, the normal T wave in all three bipolar limb leads is
positive, which is also the polarity of most of the normal
QRS complex.
The ECG Paper
The ECG Paper
 ECG Leads
Leads are electrodes which measure the
difference in electrical potential between either:

1. Two exploring (Active) electrodes attached to

the surface of body (bipolar leads)

2. One point on the body (Exploring) and a

virtual reference point (Indifferent) electrode
with zero electrical potential (unipolar leads)
 Summary of ECG Leads
Limb Leads Precordial
Leads
Bipolar I, II, III -
(standard limb leads)

Unipolar aVR, aVL, aVF V1-V6

(V leads) (augmented limb leads)
 ECG Leads
The standard ECG has 12 leads

3 Standard Limb Leads (Bipolar)

3 Augmented Limb Leads (Unipolar)
6 Precordial (chest) Leads (Unipolar)

The axis of a particular lead represents the

viewpoint from which it looks at the heart.
 Standard Bipolar Limb Leads

Einthoven’s Law. Einthoven’s law states that if the ECGs

are recorded simultaneously with the three limb leads, the
sum of the potentials recorded in leads I and III will equal
the potential in lead II.
The criteria for a ST elevation myocardial infarction (STEMI) is ST
segment elevation in two or more contiguous Leads
 U-WAVE
The U wave is a wave on an electrocardiogram that is not always seen. It is typically
small, and, by definition, follows the T wave. U waves are thought to represent
repolarization of the papillary muscles or Purkinje fibers

Normal U waves are small, round and symmetrical and positive in lead II. It is the
same direction as T wave in that lead.

Prominent U waves are most often seen in hypokalemia, but may be present
in hypercalcemia, thyrotoxicosis, or exposure to digitalis,epinephrine, and Class 1A
and 3 antiarrhythmics, as well as in congenital long QT syndrome, and in the setting
of intracranial hemorrhage.
An inverted U wave may represent myocardial ischemia or left ventricular volume
overload
HEXA AXIAL
REFERENCE
SYSTEM
DIAGRAM