Introduction to ECGs

Basics of electrocardiogram readings and how to understand what they tell you about
the heart.

Jaimie Langille, Doctorials 2018/19

 Learning Objectives
• Explain, in depth, the conduction system of the heart, emphasizing the importance of the fibrous
annulus.
• Explain the unipolar and bipolar limb leads and how they visualize the heart in the fontal plane.
• Explain the chest leads and how they visualize the heart in the horizontal plane.
• Explain, in depth, the cardiac vectors and how they relate to the normal ECG.
• Explain underlying physiology of the pathological features of an MI on ECG.

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 Heart Anatomy Review
Aortic Arch
Pulmonary Trunk
Superior Vena Cava Pulmonary Valve
Right Pulmonary Artery
Left Pulmonary Artery
Right Pulmonary Veins Left Pulmonary Veins

Left Atrium
Aortic Valve

Right Atrium Mitral Valve

Tricuspid Valve
Left Ventricle
Right Ventricle
Inferior Vena Cava

Jaimie Langille, Doctorials 2018/19 Tortora Principles of Anatomy & Physiology, 694
 Cardiac Cells
• Perform two fundamental functions of i) initiation/conduction of electrical impulses and ii) contraction.
• To accomplish this, cardiac cells possess key properties.
• Automaticity—initiate spontaneous electrical impulses.
• Contractility—shortening/contracting of cells in response to electrical impulses.
• Conductivity—ability of the cell to transmit electrical impulses to
Q: What properties do myocardial
neighboring cells.
contracting cells have?
• Excitability—ability to respond to electrical stimuli.
A: Contractility, Conductivity, Excitability.
• Overall there are two basic types of cardiac cells:
Q: What properties do myocardial
A. Myocardial contracting cells (“working cells”) conducting cells have?
• Responsible for contraction in response to stimulation, and subsequent
A: Automaticity, Conductivity, Excitability.
relaxation.
• Intercalated disks and gap junctions allow rapid electrical impulse transmission to adjacent cells.
B. Myocardial conducting cells (“electrical cells”)
• Responsible for producing and conducting electrical impulses.
• Found throughout the cardiac electrical conduction system.

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 Electrical Conduction System
• Initiates and distributes electrical impulses throughout the heart in a
systematic manner.
SA node
1) Sinoatrial (SA) Node
• Produces action potentials causing atrial depolarization.
• Location: upper right atrium, just under SVC opening
• Blood supply: RCA (55%), circumflex of LCA (45%)

Depolarizing waves travel by 2 methods:

A. General excitation
• Direct connection between SA node fibers & surrounding myocytes.
• Impulses propagated via gap junctions throughout atrium.

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 Electrical Conduction System
1) Sinoatrial (SA) Node cont.
Bachmann’s
B. Preferential pathways Bundle
1) Anterior interatrial band (Bachman’s)
SA node
• Anterior SA node, through right atrium, into left atrium.
2) Anterior internodeal tract Middle internodal
• Anterior SA node, passing SVC opening, moving down tract
atrial septum to AV node.
3) Middle internodal tract
• Posterior SA node, passing SVC opening, descending
atrial septum to AV node.
4) Posterior internodal tract
• Posterior SA node, descending through crista terminalis
and IVC opening, into AV node.
Interatrial Internodal Posterior internodal Anterior internodal
• SA node  LA • SA  AV node tract tract
Takeaways: • 1 pathway • 3 pathways
• Synchrozes atrial contraction • Direct nodal communication

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 Electrical Conduction System
2) Atrioventricular (AV) Node
• Electrical relay point between the atria and ventricles.
• Conduction of impulse slows as they move through node (AV nodal delay).
• Due to diminished number of gap junctions
• Location: floor of right atrium, above interventricular septum.
AV node
• Blood supply: RCA (90%) or circumflex of LCA (10%)
3) AV Bundle (aka Bundle of His)
• AV node continuation as it traverses through fibrous annulus.
• ONLY electrical connection between atria and ventricles (normally!).
• Specialized for one-way conduction of action potentials —prevents re-
entry of impulses from ventricles to atria.

AV bundle
Q: Why would we want a delay in impulse conduction between the atria and ventricles? (Bundle of His)
A: Ensures time for complete atrial contraction before ventricular contraction begins.

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 Electrical Conduction System
4) Bundle Branches
• Divisions of the AV bundle spreading down towards apex.
• Right bundle branch descends right side of septum.
• Left bundle branch travels short distance before dividing into anterior super
and posterior inferior divisions.

5) Purkinje Fibres
• Transmit impulses from bundle branches to cardiac muscle cells.
• Very large fibres for high velocity impulse transmission.
• Ends of fibres penetrate into muscle mass for continuous a rapid
communication with muscle fibres.
• Rapid propagation of impulses is important for effective ventricular
Right bundle branch
contractions.
Left bundle branch

Purkinje fibres

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 Pacemaker Sites
• Aggregation of cells are able to produce electrical impulses to control the heart rate.
• There are three intrinsic pacemaker sites in the conduction path.
• SA node: 60-100 bpm. SA node

• AV node: 40-60 bpm.

• Purkinje Fibres: 15-40 bpm. AV node
• Primary pacemaker is the SA node.
• Latent pacemaker cells are cells in the electrical conduction system with
property of automaticity that follow the SA node.
• Play an important role as back-up pacemakers in case the SA node fails to initiate
depolarisations or the impulse fails to be conducted.

Purkinje fibres

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 Cardiac Skeleton (Fibrous Annulus)
• Fibrous immobile framework of dense connective tissue passing transversely between the atria
and ventricles.
• Consists of annuli around the valves, and connecting trigones (triangular mass of
fibrous tissue).
• Left fibrous ring=mitral valve
• Right fibrous ring=tricuspid valve
• Pulmonary ring=pulmonary valve
• Aortic ring=aortic valve
• Fibrous trigones complete skeletal continuity, isolating atria from
ventricles.
• Majority of tissue is concentrated around the AV junction.
• AV node passage point between the AV valves.

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 Importance of Cardiac Skeleton
• Three major functions:
• Attachment points for valves and myocardium.
• Prevents the valves from over-dilating.
• Isolates electrical activity between atria and ventricles.

• Electrical Insulation
• Acts as a barrier blocking direct spread of impulses between the atria
and ventricles*.
• *AV bundle = ONLY electrical conduction point between upper
and lower chambers.
• This is a result of the poor conductive properties of fibrous tissue.

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 Electrocardiography-The 12 Lead ECG
• Provides a view of the heart’s electrical activity from 12 different ‘views’ and recorded as an ECG.
• Directions of waveform deflections depends on if the impulse is travelling towards or away from
electrode.
• Travelling towards = positive
positive deflection
deflection
• Travelling away = negative
negative deflection
• Travelling perpendicular = equiphasic
equiphasic deflection
deflection

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 Limb Leads
• View of electrical activity from frontal plane.
• Uses a combination of unipolar and bipolar leads.

• Placement:
• RA= right arm
• LA = left arm
• LL = left leg
• *RL = right left (neutral)
Trick = “Ride Your Green Bike” = Red Yellow Green Black
• Clockwise starting on right arm.

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 Limb Leads
A) Bipolar limb leads (I, II, III).
• Require a negative & positive electrode.
• Lead I: right arm (-) to left arm (+)
• Lead II: right arm (-) to left leg (+)
• Lead III: left arm (-) to left leg (+)
• Vectors combine to form Eithoven’s triangle.

B) Augmented unipolar limb leads (aVR, aVL, aVF)

• Unipolar = single positive electrode.
• Augmented = electrode is referenced against a combination of other
electrodes.
• aVR: heart to right arm
• aVL: heart to left arm
• aVF: heart vertically down to feet

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 Chest Leads
• Uses positive precordial, unipolar chest electrodes.
• Six leads placed on the chest to view the heart in the horizontal plane.
• Provides more focused information on ventricular activity.
• V1 & V2 = right ventricle
• V3 & V4 = Interventricular septum
• V5 & V6 = Left ventricle

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 ECG Waveforms
• Waves represent the sequence of depolarization and repolarization of the atria and ventricles in
one cardiac cycle.
• Does not assess contractility!!!
• Complex consists of five waveforms: P, Q, R, S, and T.
• QRS generally referred to as one unit—QRS complex.
• Segments of an ECG are sections connecting two waves without including
either wave.
• Intervals are portions of the ECG that contain a segment and one or both
waves.

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 P Wave
Represents electrical impulse conduction through the atria—aka atrial depolarization.
• Location: preceding QRS complex
• P wave before every QRS complex indicates normal sinus rhythm!
• Amplitude: 2-3 mm high
• Duration: 0.06 to 0.12 seconds.
• Configuration: rounded and upright.

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 PR Interval
Impulse passing from the atria, through the AV node, bundle of His, and bundle branches.
• Essentially represents the time between the onset of atrial and ventricular depolarization.
• Location: beginning of P wave to beginning of QRS complex.
• Duration: 0.12 to 0.20 seconds.

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 Q, R, and S Waves
Individual waves representing the impulse transmission through the different components of ventricular
conduction system.

Q wave R wave S wave

• Conduction through bundle • Depolarization of left and right • Final ventricular depolarization,
branches from left to right. ventricular free wall. at the base of the heart.
• Configuration: initial downward • Configuration: initial upward • Configuration: downward
deflection after P wave. deflection after P wave. deflection following R wave.

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 QRS Complex
A large, sharp complex representing ventricular depolarization.
• Location: following PR interval.
• Amplitude: 5 to 30 mm high (differs per lead)
• Duration: 0.06 to 0.10 seconds (half PR interval)
• Deflections: negative in aVR, V1-V3; positive in I, II, III, aVL, aVF, and V4-V6

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 ST Segment
Indicates the end of ventricular depolarization and the beginning of ventricular repolarization.
• Contains the ‘J point’ marking the end of the QRS complex.
• Location: end of the S wave beginning of T wave.
• Deflection: isoelectric—can vary from -0.5 to +1 mm in precordial leads.

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 T waves
Signifies ventricular repolarization
• Location: following S wave
• Amplitude: 0.5 mm in I, II, III; up to 10 mm in precordial.
• Configuration: round and smooth.
• Deflection: upright in I, II, V3-V6; inverted in aVR.

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 QT Interval
Measures cycle of ventricular depolarization and repolarization.
• Length is dependent on heart rate; the faster the rate, the shorter the QT interval.
• Usually lasts from 0.36 to 0.44 seconds.

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 Cardiac Axis
• Indicates the average direction of the electrical activity of the heart during ventricular
depolarization in the vertical plane.
• Normal cardiac axis is between -30 and 90.
• Degrees of deviation
• Left axis deviation: -30 to -90
• Right axis deviation: 90 to 180
• Extreme axis deviation: -90 to -180

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 Cardiac Axis—Quadrant Method
• There are multiple ways to find cardiac axis, this is just one.
• Lead I: determine if QRS complex is – or +
• Lead aVF: determine if QRS complex is – or +
• Find equiphasic QRS complex in remaining limb leads (resulting vector
perpendicular to this)

Cardiac axis of +60 = normal!

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 Determine Axis!
Positive
1) Lead I: + or –
2) Lead aVF: + or –
3) Equiphasic QRS

Equiphasic

Negative Normal axis: -30 to +90

Left axis deviation: -30 to -90
Right axis deviation: +90 to +180
Extreme axis deviation: -90 to -180
Normal/LAD at -30°.

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 Determine Axis!
Negative
1) Lead I: + or –
2) Lead aVF: + or –
3) Equiphasic QRS

Equiphasic

Positive

Normal axis: -30 to +90

Right axis deviation at +150°. Left axis deviation: -30 to -90
Right axis deviation: +90 to +180
Extreme axis deviation: -90 to -180

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 Determine Axis!
1) Lead I: + or –
2) Lead aVF: + or –
3) Equiphasic QRS
Positive

Equiphasic

Normal axis: -30 to +90

Left axis deviation: -30 to -90
Normal axis at 0°
Right axis deviation: +90 to +180
Extreme axis deviation: -90 to -180

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 Myocardial Infarctions
• Myocardial infarction (MI) results from cardiac myocyte necrosis due to prolonged myocardial
ischemia.
• The extent of the infarct is dependent on a number of factors
• Duration—acute vs. evolving. Q: What biochemical markers
would you be looking for in a
• Extent—subendocardial vs. transmural.
suspected MI?
• Anatomic location—anterior, lateral, inferior-posterior. A: troponin I & T, CK-MB.
• Baseline—prior presence of cardiac abnormalities.
• ECG only suggests acute or evolving MI; diagnosis requires changes in cardiac biomarkers.

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 Myocardial Infarction-Progression
• Complete vessel occlusion initially causes ischemia of myocardial tissue.
• Persistence of ischemia initially results in subendocardial necrosis.
• Cell death progresses in an outward wave over proceeding hours, and may reach
full thickness of the tissue wall (transmural necrosis).
• With early recognition and treatment, the progression of an MI may be stopped,
saving myocardium at risk of death.
• Characteristic changes are produced in the ECG directly overlying the region of
myocardial ischemia, injury, and death.
• Hyperactue T waves
• ST segment elevation
• Pathological Q waves
• T wave inversion

Subendocardial Transmural

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 Myocardial Infarction-ECG Changes
Hyperacute T waves
Hyperacute T Waves Normal

• Height of T waves more than 50% of preceding R wave.

• Onset: seconds to minutes following occlusion.
• Resolution: hours. Recall Question!
Q: What does the ST segment reflect?
A: End of ventricular depolarization
& beginning of ventricular repolarization.
ST Segment Elevation Hyperacute T waves Initial ST segment elevation

• Abnormalities of ventricular repolarization due to myocardial cell damage.

• ST segment elevates** (Hallmark of MI)
• Onset: <20 minutes.
• Resolution: hours to 3 days.

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 Myocardial Infarction-ECG Changes
ST Segment Elevation,
Pathological Q Waves Normal Pathological Q, T inversion

• Deeper prolonged Q wave due to lack of depolarization through necrosed

tissue.
• 2 squares deep & 1 square wide.
• Onset: 9 hours to 2 days.
• Resolution: permanent.

T Wave Inversion
• Concordant with QRS complex.
• Leads with dominant R wave have upright T wave.
• Inversion may be detected in leads directly over MI.
• Onset: highly variable.
• Resolution: highly variable.

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 Myocardial Changes-Locating
• ECG changes occur in leads overlying the areas of ischemia, injury,
aVL
infarction. aVR
I
• Key is to identify what leads contain ST segment elevations.

III II
Leads with ST Elevation MI Location Supplying Artery
aVL, I, V5, V6 Lateral Left Circumflex
aVF, II, III Inferior Right Coronary aVF
V3 & V4 Anterior Left Anterior
V1 & V2 Septal Left Anterior

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 Diagnosis?

ST segment elevation: II, III, & aVF = inferior MI

II Q: How would someone with this ECG present?

A: Chest pain > 20 min.
Unrelieved by GTN
May radiate to left arm, neck, & jaw
Thready pulse
III Autonomic symptoms (pale, clammy, sweating)

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 If all else fails

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 Resources
• Acadoodle
• Guyton & Hall Textbook of Medical Physiology
• Dubin’s Rapid Interpretation of EKG’s
• Tortora & Derrickson’s Principles of Anatomy & Physiology
• Kumar & Clark’s Clinical Medicine
• http://www.nsmu.ru/student/faculty/department/department_of_surgery/Cardiac.pdf
• https://ecg.utah.edu/img_index#item_1
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122339/
• https://www.cvphysiology.com/Arrhythmias/A013a.htm
• https://www.ncbi.nlm.nih.gov/books/NBK2214/
• https://www.medicine.mcgill.ca/physio/vlab/cardio/ECGbasics.htm

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