Fundamentals of

Electrocardiography
CHRISTINE JOY MANANTAN-RAQUID,MD,FPCP
ELECTROCARDIOGRAM

The process of These electrodes detect

recording the electrical the tiny electrical
activity of the heart over changes on the skin
a period of time using that arise from the heart
electrodes placed on a muscle depolarizing
patient's body. during each heartbeat.
WAVEFORMS OF THE NORMAL ELECTROCARDIOGRAM

REPOLARIZATION
DEPOLARIZATION WAVE
WAVE:

QRS complex T wave

P wave

Caused by Caused by Caused by

electrical potentials potentials potentials
generated when the 3waves: the Q generated as the
generated when the
atria depolarize wave, the R wave, ventricles recover
ventricles
before atrial and the S wave. from depolarization.
depolarize before
contraction begins. contraction.
 CARDIAC DEPOLARIZATION WAVES VERSUS
REPOLARIZATION WAVES

Left electrode on the Right electrode is in an

outside of the fiber is in area of positivity, which
DEPOLARIZATION an area of negativity causes the meter to
record positively.
Red positive charges inside
and red negative charges
outside, is traveling from left
to right.

First half of the fiber has

already depolarized while the
remaining half is still
polarized. Note that when depolarization has reached the halfway mark
the recording on the right has risen to a maximum positive
value.
 CARDIAC DEPOLARIZATION WAVES VERSUS
REPOLARIZATION WAVES

Recording to the right

has returned to the zero
baseline because both
electrodes are now in
areas of equal negativity.
Depolarization
has extended Completed wave is a
over the entire depolarization wave
because it results from
muscle fiber. the spread of
depolarization along the
muscle fiber membrane.
 CARDIAC DEPOLARIZATION WAVES VERSUS
REPOLARIZATION WAVES
Left electrode is in Right electrode is in an
an area of positivity area of negativity.

Halfway
repolarization Consequently, the
recording, as shown to
positivity returns to
the right, becomes
the outside of the
negative
fiber.
 CARDIAC DEPOLARIZATION WAVES VERSUS
REPOLARIZATION WAVES

Completely
repolarized Recording on the right,
the potential returns once
Both electrodes are more to zero.
now in areas of
positivity so that no Completed negative wave
potential difference is is a repolarization wave
recorded between REPOLARIZATION WAVE

them.
MONOPHASIC Action Upsweep of this action potential is caused by depolarization
potential of ventricular
muscle lasts between
0.25 and 0.35 second. Return of the potential to the baseline is caused by repolarization.

QRS waves appear at the

Relation of the beginning of the monophasic
action potential, and the T wave
Monophasic appears at the end.
Action Potential
of Ventricular
Muscle to the QRS waves appear at the
beginning of the monophasic
QRS and T action potential, and the T wave
Waves in the appears at the end.
Standard ECG
 RELATIONSHIP OF ATRIAL AND VENTRICULAR
CONTRACTION TO THE WAVES OF THE
ELECTROCARDIOGRAM
Depolarization Atria repolarize about 0.15 to 0.20
must spread
through the
P wave occurs second after termination of the P wave,
which is also approximately when the
QRS complex is being recorded in the
muscle to
initiate the
at the ECG.

chemical beginning of
processes of
contraction. contraction of Atrial repolarization wave, known as the
atrial T wave, is usually obscured by the
much larger QRS complex.
the atria

Ventricles remain contracted until after

QRS complex repolarization has occurred—that is,
until after the end of the T wave.

of waves
Ventricular repolarization wave is the T
occurs at the wave of ECG.

beginning of
contraction of Ventricular muscle begins to repolarize
0.20 to 0.0.35 second after the

the ventricles. beginning of the depolarization wave

(the QRS complex).
ELECTROCARDIOGRAPHIC
CALIBRATION AND DISPLAY

Horizontal calibration:
10 of the small line (10 small small
squares) divisions upward or downward
represent 1 millivolt with positivity in the
upward direction and negativity in the
downward direction.
Amplitude of a specific wave or deflection
(1 mV = 10 mm with standard calibration
 The usual paper speed is 25mm/sec:
ECG Paper: •1mm (small square) = 0.04 sec
•5mm (big square) = 0.2 sec

Vertical lines on the ECG are time calibration lines. A

typical ECG is run at a speed of 25 millimeters per
second.

Each 25 millimeters in the horizontal direction is 1

second

Each 5-millimeter segment represents 0.20 second.

Each 1mm represents 0.04 second.

 P-Q or P-R Interval

Often, this interval is called the P-R interval because the Q wave is likely to be absent.
PQ
interval: Measure from the beginning of the P wave and the beginning of the QRS.

Interval between the beginning of electrical excitation of the atria and the beginning of
excitation of the ventricles.

P-Q interval is about 0.16 second.

Shortens at faster heart rates due to increased sympathetic or decreased parasympathetic

activity.

Lengthens with slower heart rates as a consequence of slower atrioventricular nodal

conduction caused by increased parasympathetic tone or withdrawal of sympathetic activity.

Q-T Contraction of the ventricle lasts almost from the beginning of the Q wave (or R wave, if the Q
wave is absent) to the end of the T wave.

Interval. QT interval is about 0.35 second

Heart Rate as Determined
from the Electrocardiogram
Heart rate time interval between two
successive heartbeats (the R-R
interval).

The normal interval between two successive QRS

complexes in an adult is about 0.83 second or 72
The normal interval between two successive QRS complexes in an adult is about 0.83 second, which is a heart rate of 60/0.83 times/min, or 72 beats/min

beats/min
 FLOW OF CURRENT AROUND THE
HEART DURING THE CARDIAC CYCLE
Recording Electrical Potentials from a Partially Depolarized Mass of
Syncytial Cardiac Muscle

Syncytial mass of cardiac muscle that has been stimulated at its most
central point. Before stimulation, all the exteriors of the muscle cells
had been positive, and the interiors had been negative.

As soon as an area of cardiac syncytium becomes depolarized,

negative charges leak to the outsides of the depolarized muscle fibers,
making this part of the surface electronegative, as represented by the
minus signs.

The remaining surface of the heart, which is still polarized, is

represented by the plus signs.

Therefore, a meter connected with its negative terminal on the area of

depolarization and its positive terminal on one of the still polarized
areas, as shown to the right in the figure, records positively.
 NORMAL HEART VENTRICLES, CURRENT FLOWS FROM NEGATIVE TO POSITIVE
PRIMARILY IN THE DIRECTION FROM THE BASE OF THE HEART TOWARD THE
Flow of Electrical APEX DURING ALMOST THE ENTIRE CYCLE OF DEPOLARIZATION, EXCEPT AT THE
VERY END.
Currents in the Chest
Around the Heart Electrical current flows from the depolarized area to the polarized area.

Cardiac impulse first arrives in the ventricles in the septum and shortly thereafter spreads
to the inside surfaces of the remainder of the ventricles.
Process provides electronegativity on the insides of the ventricles and electropositivity on
the outer walls of the ventricles.

Current flow occurs with negativity toward the base of the heart and with positivity toward
the apex.

During most of the remainder of the depolarization process, current also continues to flow
in this same direction, whereas depolarization spreads from the endocardial surface
outward through the ventricular muscle mass.

Then, immediately before depolarization has completed its course through the ventricles,
the average direction of current flow reverses for about 0.01 second, flowing from the
ventricular apex toward the base, because the last part of the heart to become depolarized
is the outer walls of the ventricles near the base of the heart.
Standard Bipolar Limb Leads Lead I.
Electrical connections between the patient’s limbs and the • Negative terminal : right arm
electrocardiograph for recording ECGs • Positive terminal : left arm.
• Point where the right arm connects to the
Bipolar means that the ECG is recorded from two electrodes chest is electronegative with respect to
located on different sides of the heart—in this case, on the limbs. the point where the left arm connects, the
electrocardiograph records positively.
Lead II.
• Negative terminal : right arm
• Positive terminal : left leg.
• When the right arm is negative with
respect to the left leg, the
electrocardiograph records positively.
Lead III.
• Negative terminal : left arm
• Positive terminal : left leg.
• Electrocardiograph records positively
when the left arm is negative with respect
to the left leg
Standard Bipolar Limb Leads Lead I.
• Negative terminal : right arm
• Positive terminal : left arm.
• Point where the right arm connects to the
chest is electronegative with respect to
the point where the left arm connects, the
electrocardiograph records positively.
Lead II.
• Negative terminal : right arm
• Positive terminal : left leg.
• When the right arm is negative with
respect to the left leg, the
electrocardiograph records positively.
Lead III.
• Negative terminal : left arm
• Positive terminal : left leg.
• Electrocardiograph records positively
when the left arm is negative with respect
to the left leg
 EITHOVENS TRIANGLE and LAW

Eithoven’s
Illustrates that the two arms and left leg form apices of a
Triangle triangle surrounding the heart.

Einthoven’s If the ECGs are recorded simultaneously with the three limb
Law. leads, the sum of the potentials recorded in leads I and III will
equal the potential in lead II:

Right arm is −0.2 millivolts (negative) with respect to the

average potential in the body.
Einthoven’s
Triangle
Left arm is +0.3 millivolts (positive)

Left leg is +1.0 millivolts (positive).

Sum of voltages in leads I and III equals the voltage in lead II;
that is, 0.5 plus 0.7 equals 1.2.
Augmented Limb Leads
Two of the limbs When the
are connected
through electrical
resistances to the
aVR positive
terminal is on
negative terminal of
the
electrocardiograph,
lead the right arm
and the third limb is
connected to the When the
positive terminal.
aVL positive
terminal is
lead on the left
arm

When the
aVF positive
terminal is
lead on the left
leg
 PRECORDIAL LEADS
PRECORDIAL LEADS
Electrode is connected to the positive terminal of the electrocardiograph, and
the negative electrode, called the indifferent electrode or Wilson central
terminal, is connected through equal electrical resistances to the right arm, left
arm, and left leg all at the same time
Six standard chest leads are recorded, one at a time, from the anterior chest
wall, with the chest electrode being placed sequentially at the six points.

Recordings are known as leads V1, V2, V3, V4, V5, and V6.
 PRECORDIAL LEADS

• In leads V1 and V2, the QRS

recordings of the normal heart are
mainly negative because, the chest
electrode in these leads is closer to the
base of the heart than to the apex, and
the base of the heart is the direction of
electronegativity during most of the
ventricular depolarization process.
• Conversely, the QRS complexes in
leads V4, V5, and V6 are mainly
positive because the chest electrode in
these leads is closer to the heart apex,
which is the direction of electropositivity
during most of depolarization.
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