Basics of ECG

KARTHIK SUDHARSAN P.N

20770680
 OBJECTIVES
❖To have basic understanding of ECG waves &
intervals.
❖Interpretation of ECG
❖ Outline the criteria for the most common
electrocardiographic diagnosis in adults.
❖Describe critical aspects of the clinical application of
the ECG
 HISTORY
❖1842- Italian scientist Carlo Matteucci realizes that electricity
is associated with the heart beat.
❖1895 - William Einthoven , credited for the invention of ECG.

❖1906 - using the string electrometer ECG,William Einthoven

diagnoses some heart problems.
❖1924 - The noble prize for physiology or medicine is given to
William Einthoven for his work on ECG
 ELECTROCARDIOGRA
M
❖The electrocardiogram (ECG) is a
representation of the electrical events of the
cardiac cycle.
❖We are recording the direction and
amplitude of instantaneous cardiac vector
❖Each event has a distinctive waveform, the
study of waveform can lead to greater insight
into a patient’s cardiac pathophysiology.
 ECGs can identify
1. Arrhythmias
2. Myocardial ischemia and infarction
3. Pericarditis
4. Chamber hypertrophy
5. Electrolyte disturbances (i.e. hyperkalemia,
hypokalemia)
6. Drug toxicity (i.e. digoxin and drugs which
prolong the QT interval)
Fundamental Principles
❖Transmembrane ionic currents are generated by ion fluxes
across cell membranes and between adjacent cells.
❖These currents are synchronized by cardiac activation and
recovery sequences to generate a cardiac electrical field in
and around the heart that varies with time during the
cardiac cycle.
❖The currents reaching the skin are then detected by
electrodes placed in specific locations on the extremities
and torso that are configured to produce leads.
Fundamental Principles
❖Transmembrane ionic currents are ultimately responsible
for the potentials that are recorded as an ECG.
❖Electrophysiological currents are considered to be the
movement of positive charge.
❖An electrode senses positive potentials when an activation
front is moving toward it and negative potentials when the
activation front is moving away from it.
 Depolarization

⚫ Contraction of any muscle is associated

with electrical changes called
depolarization.
⚫ These changes can be detected by
electrodes attached to the surface of the
body.
Repolarization
⚫Phase of recovery/relaxation.
⚫The dipole moment at any one instant during recovery is
less than during activation.
⚫Recovery, is a slow process, lasts 100 msec or longer and
occurs simultaneously over extensive portions of the fiber.
 Pacemakers of the Heart
❖SA Node - Dominant pacemaker with an intrinsic rate of 60 -
100 beats/minute.

❖AV Node - Back-up pacemaker with an intrinsic rate of 40 - 60

beats/minute.

❖Ventricular cells - Back-up pacemaker with an intrinsic rate of

20 - 45 bpm.
The Normal Conduction System
 ECG Leads
Measure the difference in electrical potential
between two points
1. Bipolar Leads: Two different points on the body.

2. Unipolar Leads: One point on the body and a virtual

reference point with zero electrical potential, located in the
center of the heart .
 ECG Leads
The standard ECG has 12 leads:

3 Standard Limb Leads

3 Augmented Limb Leads
6 Precordial Leads
Recording of the ECG
❖Limb leads are I, II, II.
❖Each of the leads are bipolar; i.e., it requires two sensors on
the skin to make a lead.
❖If one connects a line between two sensors, one has a vector.
❖There will be a positive end at one electrode and negative at
the other.
❖The positioning for leads I, II, and III were first given by
Einthoven (Einthoven’s triangle).
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
All Limb Leads
Standard Chest Lead Electrode Placement
The Right-Sided 12-Lead ECG The 15-Lead ECG
Precordial Leads
The ECG Paper
1. Horizontally
a. One small box - 0.04 s
b. One large box - 0.20 s
2. Vertically
a. One large box - 0.5 mV
Clinical Interpretation of the ECG

⚫Accurate analysis of ECGs requires

thoroughness and care.
⚫The patient's age, gender, and clinical status
should always be taken into account.
⚫Many mistakes in ECG interpretation are
errors of omission. Therefore, a systematic
approach is essential.
NORMAL ECG
NORMAL ECG
The following 14 points should be analyzed carefully in every
ECG:
1. Standardization (calibration) and technical features (including
lead placement and artifacts)
2. Rhythm
3. Heart rate,
4. PR interval/AV conduction
5. QRS interval
6. QT/QTc interval
7. Mean QRS electrical axis
8. P waves
9. QRS voltages
10. Precordial R-wave progression
11. Abnormal Q waves
12. ST segments
13. T waves
14. U waves
Standardization
❖The first step while reading ECG is to look for whether
standardization is properly done.
❖Look for the vertical mark and see that the mark exactly covers
two big squares(10 mm or 1mV) on the graph.
❖Standard calibration
❖25 mm/s
❖0.1 mV/mm
Standardization
RHYTHM
❖Evaluate the rhythm strip at the bottom of the 12-lead for
the following-
❖Is the rhythm regular or irregular?
❖Is there a P wave before every QRS complex?
1.Are there any abnormal beats?
The Heart Rate

1. Rule of 300/1500(Regular
rhythm)
2. 10 Second Rule(Irregular
rhythm)
 Rule of 300
For Regular rhythms

Count the number of “big boxes” between two

QRS complexes, and divide this into 300.
(smaller boxes with 1500) for regular rhythms.
Rule of 300

(300 / 6) = 50 bpm
Heart rate?

(300 / ~ 4) = ~ 75 bpm
Heart rate?

(300 / 1.5) = 200 bpm

 10 Second Rule
For irregular rhythms

Count the number of beats present on the ECG during

1o seconds(i.e 50 big squares).
Multiply them by 6
 Heart rate?

33 x 6 = 198 bpm
Normal intervals

(3-5 small
box)
The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)
(delay allows time for the
atria to contract before the
ventricles contract)
 Normal PR interval
⚫0.12 to 0.20 s (3 - 5 small squares).
⚫Short PR – Wolff-Parkinson-White.
⚫Long PR – 1st Degree AV block
Long PR Interval
❖First degree Heart Block
First Degree AV Block
❖Delay in the conduction through the conducting system
❖Prolong P-R interval
❖All P waves are followed by QRS
❖Associated with : Acute Rheumatic Carditis, Digitalis, Beta
Blocker, excessive vagal tone, ischemia, intrinsic disease in
the AV junction or bundle branch system.
Short PR Interval
QRS INTERVAL(DURATION)
❖Normal QRS duration is 110-120 msec.
❖Intrinsic impairment of conduction in either the right or
the left bundle system (intra ventricular conduction
disturbances) leads to prolongation of the QRS interval.
❖With complete bundle branch blocks, the QRS interval
exceeds 120 ms in duration; with incomplete blocks, the
QRS interval is between 110 and 120 msec.
QT Interval
QT INTERVAL
❖It includes the total duration of ventricular activation and
recovery.
❖When the interval is to be measured from a single lead, the
lead in which the interval is the longest, most commonly lead
Avl, V2 or V3, and in which a prominent U wave is absent
should be used.
❖The normal range for the QT interval is rate-dependent
❖A commonly used formula was developed by Bazett in 1920.
The result is a corrected QT interval, or QTc, defined by the
following equation:
❖QTc=QT/ RR
QT INTERVAL
⚫The upper normal limit be set at 450 or even
460 msec.
⚫The Bazett formula remains significantly
affected by heart rate and that as many as
30% of normal ECGs would be diagnosed as
having a prolonged QT interval when this
formula is used.
⚫One formula that has been shown to be
relatively insensitive to heart rate is-
QTc= QT +1.75(HR-60)
Prolonged QTc
❖During sleep
❖Hypocalcemia
❖Acute myocarditis
❖Acute Myocardial Injury
❖Drugs like quinidine, procainamide, tricyclic
antidepressants
❖Hypothermia
❖HOCM
Prolonged QTc
❖Advanced AV block or high degree AV block
❖Jervell-Lange –Neilson syndrome
❖Romano-ward syndrome
Shortened QT
❖Digitalis effect
❖Hypercalcemia
❖Hyperthermia
❖Vagal stimulation
The “PQRST”

P wave - Atrial
depolarization

❖ QRS - Ventricular
depolarization

❖ T wave - Ventricular
repolarization
 P wave

❖Always positive in lead I and II

❖Always negative in lead aVR
❖< 3 small squares i.e 0.12sec in
duration
❖< 2.5 small squares(2.5mm) in
amplitude
❖Commonly biphasic in lead V1
❖Best seen in leads II
Atrial abnormality
 Right Atrial Enlargement
❖Tall (> 2.5 mm), pointed P waves (P Pulmonale)

The P waves are tall, especially in leads II, III and avF.
Left Atrial Enlargement
⚫Notched/bifid (‘M’ shaped) P wave (P
‘mitrale’) in limb leads
 Left atrial enlargement
⚫ To diagnose LAE you can use the following criteria:
⚫ Lead II > 0.04 s between notched peaks, or
⚫ V1 deflection > 0.04 s wide x 1 mm deep

Normal LAE
 Left atrial enlargement

Notched

Negative deflection

The P waves in lead II are notched and in lead V1 they have

a deep and wide negative component.
QRS Complex

Q waves
Normal QRS

V1
V6
Normal QRS

Septal r wave

Septal q wave
QRS Complexes
❖Normal QRS patterns in the precordial leads follow an orderly
progression from right (V1) to left (V6).
❖In leads V1 and V2, left ventricular free wall activation
generates S waves following the initial r waves generated by
septal activation (an rS pattern).
❖As the exploring electrode moves laterally to the left, the R
wave becomes more dominant and the S wave becomes
smaller (or is totally lost).
❖In the leftmost leads (i.e., leads V5 and V6), the pattern also
includes the septal q wave to produce a qRs or qR pattern.
IWMI
Normal R Wave Progression

Transition Zone?
Early & Delayed Transition
V1 V2 V3 V4 V5 V6

• Figure 4-7
QRS Complexes
❖Non­pathological Q waves may present in I, III, aVL,
V5, and V6
❖Pathological Q wave > 2mm deep and > 1mm wide or
> 25% amplitude of the subsequent R wave
QRS in LVH & RVH
Left Ventricular Hypertrophy
❖Sokolow & Lyon Criteria
S in V1+ R in V5 or V6 > 35 mm
❖An R wave of 11mm (1.1mV) or more in lead aVL
is another sign of LVH
Right ventricular hypertrophy
❖ To diagnose RVH you can use the following criteria:
❖ Right axis deviation, and
❖ V1 R wave > 7mm tall
 ST Segment
❖ST Segment is flat (isoelectric)
❖Elevation or depression of ST segment by 1 mm or
more is significant.
❖“J” (Junction) point is the point between QRS and
ST segment
The J Point

❖J point – where the QRS complex and ST segment

meet
❖ST segment elevation - evaluated 0.04 seconds
(one small box) after J point
Variable Shapes Of ST Segment Elevations in AMI

Goldberger AL. Goldberger: Clinical Electrocardiography: A

Simplified Approach. 7th ed: Mosby Elsevier; 2006.
 T wave
❖Normal T wave is asymmetrical, first half having a
gradual slope than the second.

❖Should be at least 1/8 but less than 2/3 of the

amplitude of the R.

❖T wave amplitude rarely exceeds 10 mm.

❖Abnormal T waves are symmetrical, tall, peaked,

biphasic or inverted.

❖T wave follows the direction of the QRS deflection.

T wave
U wave
❖U wave related to afterdepolarizations which
follow repolarization
❖U waves are small, round, symmetrical and
positive in lead II, with amplitude < 2 mm
❖U wave direction is the same as T wave
❖More prominent at slow heart rates
PREMATURE VENTRICULAR
CONTRACTION
Premature Atrial Contractions

❖Deviation from NSR

❖These ectopic beats originate in the atria (but not in
the SA node), therefore the contour of the P wave, the
PR interval, and the timing are different than a
normally generated pulse from the SA node.
Anatomic Groups
Anatomic Groups
Anatomic Groups
Anatomic Groups
Anatomic Groups