Cardiology Teaching Package

A Beginners Guide to Normal Heart Function, Sinus Rhythm & Common Cardiac Arrhythmias
ECG Lead Placement
The system of positioning of leads for performing a 12-lead ECG is universal. This helps to
ensure that, when a person's ECGs are compared, any changes on the ECG are due to
cardiac injury, not a difference in placement of leads, this is extremely important with the
increasing use of foreign travel. There are universal standards in place throughout the
world.
Interpretation of the findings can vary from doctor to doctor but methods for obtaining the
information are the same the world over.
These positions may differ slightly when a patient is on continuous cardiac monitoring. The
leads routinely attached to wrists and ankles will be placed on shoulders and lower abdomen
so that movement of limbs has minimal effect on the rhythm trace.
These positions may also differ if a patient is shaking (maybe due to Parkinson's Disease or
hypothermia) or has muscle tremors. In this situation the leads may be moved onto the
thighs and forearms.
Seeing an ECG being performed will look something like the scene below. As you can see,
the peripheral leads are correctly placed on wrists and ankles.
Image: Patient undergoning and ECG


Chest Leads
There are 10 wires on an ECG machine that are connected to specific parts of the body.
These wires break down into 2 groups:
1. 6 chest leads
2. 4 limb or peripheral leads (one of these is "neutral")
The 6 chest leads are positioned as below:
Image: Positioning of the 6 chest leads

The 6 leads are labelled as "V" leads and numbered V1 to V6. They are positioned in specific
positions on the rib cage. To position then accurately it is important to be able to identify
the "angle of Louis", or "sternal angle".
To find it on yourself, place your fingers gently at the base of your throat in a central
position and move your fingers downward until you can feel the top of the sternum, or rib
cage. From this position, continue to move your fingers downward until you feel a boney
lump. This is the "angle of Louis".
The angle of Louis is most easily found when the patient is lying down as the surrounding
tissue is tighter against the rib cage.
From the angle of Louis, move your fingers to the right and you will feel a gap between the
ribs. This gap is the 2nd Intercostal space. From this position, run your fingers downward
across the next rib, and the next one. The space you are in is the 4th intercostal space.
Where this space meets the sternum is the position for V1.
Go back to the "angle of Louis" and move into the 2nd intercostal space on the left. Move
down over the next 2 ribs and you have found the 4th intercostal space. Where this space
meets the sternum is the position for V2.
From this position, slide your fingers downward over the next rib and you are in the 5th
intercostal space . Now look at the chest and identify the left clavicle, a bone that runs from
the left shoulder to the top of the sternum. The position for V4 is in the 5th intercostal
space , in line with the middle of the clavicle (mid-clavicular). V3 sits midway between V2
and V4.
Follow the 5th intercostal space to the left until your fingers are immediately below the
beginning of the axilla, or under-arm area. This is the position for V5.
Follow this line of the 5th intercostal space a little further until you are immediately below
the centre point of the axilla, (mid-axilla). This is the position for V6.
Now look at the picture below showing the position of the heart in relation to the rib-cage
and you get an idea as to which areas are being looked at by these leads.
Image: Heart position in relation to the rib cage




Limb Leads
Limb leads are made up of 4 leads placed on the extremities: left and right wrist; left and
right ankle.
The lead connected to the right ankle is a neutral lead, like you would find in an electric
plug. It is there to complete an electrical circuit and plays no role in the ECG itself.
Image: Position of Limb Leads

Role of the ECG Machine
The ECG machine is designed to recognise and record any electrical activity within the
heart. It prints out this information on ECG paper made up of small squares 1mm squared.
Image: ECG paper

Each electrical stimulus takes the form of a wave and so patterns emerge made up of a
number of connected waves. A standard ECG is printed at 25mm per second or 25 small
squares per second (see above). In this way it is possible to calculate the duration of
individual waves.
10 small squares vertically is equal to 1 millivolt. So it is possible to calculate the amount of
voltage being released within the heart. If the line is flat at any time in the duration of a
series of waves, it indicates no electrical activity at that particular moment.
The direction in which the waves point indicates whether electricity is moving towards or
away from a particular lead.
The general direction in which electricity normally travels through the heart is a downward
diagonal line from the right shoulder to the left lower abdomen. This is because the
electrical stimulus originates in the SA node (upper right side of the heart), travels through
the AV node and bundle of His, and finishes mainly in the left ventricle. (remember that
there is more conduction in the left ventricle).
So different leads may have waves pointing in different directions. Eg. Lead AVR
(right shoulder/right arm/wrist) will always see the electrical stimulus travelling away from
it, therefore the waves expressed in AVR for sinus rhythm, pqrst, will all point downwards.
Image: Rhythm strip of sinus rhythm recorded from ECG lead AVR

Similarly, lead V6 (mid-left axilla, 5th intercostal space), will always see the electrical
stimulus coming towards it and therefore the waves expressed in V6 for sinus rhythm,
pqrst, will always be point upwards.
Image: Rhythm strip of sinus rhythm recorded from ECG lead V6