Cardiology Teaching Package

A Beginners Guide to Normal Heart Function, Sinus Rhythm & Common Cardiac
Arrhythmias

The Heart
The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. De-oxygenated blood
returns to the right side of the heart via the venous circulation. It is pumped into the right
ventricle and then to the lungs where carbon dioxide is released and oxygen is absorbed. The
oxygenated blood then travels back to the left side of the heart into the left atria, then into the
left ventricle from where it is pumped into the aorta and arterial circulation.
Image: The passage of blood through the heart

The pressure created in the arteries by the contraction of the left ventricle is the systolic blood
pressure. Once the left ventricle has fully contracted it begins to relax and refill with blood
from the left atria. The pressure in the arteries falls whilst the ventricle refills. This is the
diastolic blood pressure.
The atrio-ventricular septum completely separates the 2 sides of the heart. Unless there is a
septal defect, the 2 sides of the heart never directly communicate. Blood travels from right
side to left side via the lungs only. However the chambers themselves work together . The
2 atria contract simultaneously, and the 2 ventricles contract simultaneously.
So what we need to know next is "what causes these chambers to contract?".

Cardiac Conduction System

Going back to the analogy of the central heating system, the pump, pipes and radiators are of
no use unless connected to a power supply. The pump needs electricity to work. The human
heart has a similar need for a power source and also uses electricity. Thankfully we don't need

to plug ourselves in to the mains, the heart is able to create it's own electrical impulses and
control the route the impulses take via a specialised conduction pathway.
This pathway is made up of 5 elements:
1. The sino-atrial (SA) node
2. The atrio-ventricular (AV) node
3. The bundle of His
4. The left and right bundle branches
5. The Purkinje fibres
Image: The cardiac conduction system

The SA node is the natural pacemaker of the heart. You may have heard of permanent
pacemakers (PPMs) and temporary pacing wires (TPWs) which are used when the SA node
has ceased to function properly.
The SA node releases electrical stimuli at a regular rate, the rate is dictated by the needs of
the body. Each stimulus passes through the myocardial cells of the atria creating a wave of
contraction which spreads rapidly through both atria.
As an analogy, imagine a picture made up of dominoes. One domino is pushed over causing a
wave of collapsing dominoes spreading out across the picture until all dominoes are down.
The heart is made up of around half a billion cells, In the picture above you can see the
difference in muscle mass of the various chambers. The majority of the cells make up the
ventricular walls. The rapidity of atrial contraction is such that around 100 million

myocardial cells contract in less than one third of a second. So fast that it appears
instantaneous.
The electrical stimulus from the SA node eventually reaches the AV node and is delayed
briefly so that the contracting atria have enough time to pump all the blood into the
ventricles. Once the atria are empty of blood the valves between the atria and ventricles close.
At this point the atria begin to refill and the electrical stimulus passes through the AV node
and Bundle of His into the Bundle branches and Purkinje fibres.
Imagine the bundle branches as motorways, if you like, with the Purkinje fibres as A and B
roads that spread widely across the ventricles . In this way all the cells in the ventricles
receive an electrical stimulus causing them to contract.
Using the same domino analogy, around 400 million myocardial cells that make up the
ventricles contract in less than one third of a second. As the ventricles contract, the right
ventricle pumps blood to the lungs where carbon dioxide is released and oxygen is absorbed,
whilst the left ventricle pumps blood into the aorta from where it passes into the coronary and
arterial circulation.
At this point the ventricles are empty, the atria are full and the valves between them are
closed. The SA node is about to release another electrical stimulus and the process is about to
repeat itself. However, there is a 3rd section to this process. The SA node and AV node
contain only one stimulus. Therefore every time the nodes release a stimulus they must
recharge before they can do it again.
Imagine you are washing your car and have a bucket of water to rinse off the soap. You
throw the bucket of water over the car but find you need another one. The bucket does not
magically refill. You have to pause to fill it.
In the case of the heart, the SA node recharges whilst the atria are refilling, and the AV node
recharges when the ventricles are refilling. In this way there is no need for a pause in heart
function. Again, this process takes less than one third of a second.
The times given for the 3 different stages are based on a heart rate of 60 bpm , or 1 beat per
second.
The term used for the release (discharge) of an electrical stimulus is "depolarisation", and the
term for recharging is "repolarisation".
So, the 3 stages of a single heart beat are:
1. Atrial depolarisation
2. Ventricular depolarisation
3. Atrial and ventricular repolarisation.
As the atria repolarise during ventricular contraction, there is no wave representing
atrial repolarisation as it is buried in the QRS.

Cardiology Teaching Package

A Beginners Guide to Normal Heart Function, Sinus Rhythm & Common Cardiac
Arrhythmias

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

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

Unipolar Leads
But, wait a minute. That gives us nine wires and it is a 12-lead ECG. Where are the other 3?

Well, so far we have nine wires. They all look directly at the heart with tunnel vision. They
only give information based on what is immediately in front of them. These nine wires are
known as "unipolar leads".
The three active peripheral leads are AVr, AVL, and AVf.
The "AV" stands for "Augmented Vector". The last letter refers to position, which are as
follows:
Label
AVr
AVL
AVf

Meaning of label
Augmented vector right
Augmented vector left
Augmented vector foot

Position of lead on body

Right wrist
Left wrist
Left foot

These 3 leads create a triangle with the heart in the middle, as below. The lines into the centre
indicate the line of sight of these leads.
Image: Line of site of the unipolar leads