CARDIOVASCULAR

A.Y. 2019-2020 | Module 4

4.7 Intro to Electrocardiogram
Dr. Lapak | Oct. 18, 2019
LEARNING OUTCOMES  When this wave of positive charges ions moves
1. Identify the waves in an electrocardiogram and what toward a positive electrode, there is a simulta-
it represents neous upward deflection recorded on the EKG.
2. Identify the heart rate, P-Q interval, Q-T interval,  When the electrical activity is going from a neg-
rhythm, and QRS axis by interpreting the ECG ative pole towards a positive pole, there is a
3. Apply the interpretations to clinical cases corresponding upward deflection of the waves.
4. Discuss the different leads and its anatomical position
5. Identify the difference between adult ECG and pediat-  When electrical activity is going away from a
ric ECG positive pole towards the negative pole, there is
6. Interpret an ECG recording a downward deflection.
 The normal anatomical position of the heart is
OUTLINE
slightly to the left and down, therefore, the di-
I. ELECTROCARDIOGRAM rection of its electrical activity also goes left
II. CARDIAC CYCLE
A. ECG waves
III. ECG LEADS
A. Bipolar Leads
B. Unipolar Leads
IV. RHYTHM
V. PARTS OF AN ECG TRACING
VI. RELATIONSHIP OF BODY TEMPERATURE TO HEART RATE
VII. RIGHT ATRIAL ENLARGMENT, LEFT ATRIAL ENLARGEMENT
VIII. COMBINED ATRIAL HYPERTROPHY
IX. PREMATURE VENTRICULAR CONTRACTION (PVC)
X. HEXAXIAL REFERENCE Figure 1. Contractions in the heart are controlled via a well-
XI. QRS AXIS regulated electrical signaling cascade that originates in pace-
maker cells in the sinoatrial (SA) node and is passed via inter-
ELECTROCARDIOGRAM modal pathways to the atrioventricular (AV) node, the bundle
 Provides a record of electrical cardiac activity and valua- of His, the Purkinje system, and to all parts of the ventricle
ble information about the heart’s structure and function. CARDIAC CYCLE
 A tool for supporting the diagnosis and management of
 Represents atrial systole (atrial contraction), followed
abnormal cardiac rhythms or problems. by ventricular systole (ventricular contraction) and the
 Electrodes is used to define ECG leads which displays resting stage that follows until another cycle begins.
instantaneous differences in potential between two elec-  Represented by the P wave, the QRS complex, the T
trodes. wave and the baseline that follows until another P
P wave – atrial depolarization (and contraction)
Basic Principles of ECG PR interval - impulse conduction through the AV node
 A wave depolarization advancing through the myo- QRS complex – ventricular depolarization (and con-
cardium is a moving wave of positive charges traction)
ions. ST segment – “plateau” (initial) phase of ventricular
repolarization
T wave – rapid phase of ventricular repolarization
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CARDIOVASCULAR 4.7 1
 4.7 Introduction to Electrocardiogram
Recording the ECG

Figure 2. Cardiac Cycle

The movement of three types of ions determines all aspects of
cardiac conduction, contraction and repolarization:
 The release of free Ca2+ ions into the interiors of
the myocytes produces myocardial contraction
 Following depolarization, repolarization is due to
the controlled outflow of K+ ions from the myo-
cytes Figure 4. Sample ECG paper
 Cell-to-cell conduction of depolarization
through the myocardium is carried by Na+ ions,  EKG is recorded on ruled (graph) paper
however, AV node conduction is due to slow move-  The smallest divisions are 1mm long and 1mm
ment of Ca2+ ions high
 Between the heavy black line there are 5 small
squares
 Each large square is formed by heavy black
lines on each side, each side is 5mm long.

Figure 3. Ionic movements during Cardiac Cycle

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 4.7 Introduction to Electrocardiogram

Figure 5. Horizontal Axis

 Horizontal axis – time or duration; Figure 6. Limb Leads vs. Chest Leads
 1 small box = 0.04 sec
 1 big box = 0.04 x 5 = 0.2 sec
 Vertical axis – voltage or amplitude of the impulse
 1 small box = 0.1 mV
 1 big box = 0.5 mV
To ensure that ECG is calibrated it should show the conversion: 1
millivolt = 10 mm (equivalent to 10 small boxes)

Figure 7. Location of the different ECG Limbs

Limb Leads
 Limb Leads
 Set up: Attach electrodes on right arm, left arm
and left leg;

BIPOLAR LIMB LEADS – paired electrodes; one is positive

Figure 3. Ionic movements during Cardiac Cycle and the other is negative.

ECG LEADS  Lead I (+) electrode: left arm

 Standard ECG has 12 leads (-) electrode: right arm
 Leads = those seen in paper  Current flows toward the left lateral wall
 Electrodes = those attached to the skin  This lead defines an axis in the frontal
 2 sets: plane at 0 degrees (Boron)
a. Limb leads (6 individual leads)
b. Chest leads (6 individual leads)
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 4.7 Introduction to Electrocardiogram
 Lead II (+) electrode: left leg
(-) electrode: right arm
 Current flows toward Inferior wall
 Commonly used for cardiac monitoring
 This lead defines an axis in the frontal
plane at 60 degrees (Boron)
 Positioning of electrodes most closely re-
semble current flow pathway in the heart
 Lead III (+) electrode: left leg
(-) electrode: left arm
 Downward and right flow of current
 This lead defines an axis in the frontal
plane at 120 degrees (Boron)
Figure 8. Bipolar Limb Leads (referred to as Einthoven’s tri-
angle)
Figure 9. Bipolar Limb Leads if moved to intersect at a center
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UNIPOLAR/AUGMENTED LIMB LEADS – augments or
amplify the voltages of the bipolar leads which have small
measuring capacity
 Difference is that augmented leads are only unipolar
(positive (+) only)
Lead AVF (Augmented Voltage Foot)
 Positive to left leg [foot], negative is middle of
the heart.
 The axis defined by this limb lead in the frontal
plane is +90 degrees.
Lead AVR (Augmented Voltage Right arm)
 Positive connection to right arm, negative con-
nection is electronically defined in the
middle of the heart.
 The axis defined by this limb lead in the frontal
plane is −150 degrees.
Lead AVL (Augmented Voltage Left arm)
 Positive to left arm, negative is middle of the
heart.
 The axis defined by this limb lead in the frontal
plane is −30 degrees.
Figure 10. Augmented leads (unipolar leads)
CARDIOVASCULAR 4.7 4
 4.7 Introduction to Electrocardiogram

Figure 11. Augmented Limb Leads if moved to intersect at a

center point Figure 14. Six Limb Leads at six different angles
NOTE: Limitation of the Limb leads is that it records only
electrical activity along the frontal plane to the heart not
including the horizontal/ transverse plane.

Figure 12. Combination of Bipolar and Augmented Limb leads

forms the Hexa-axial system (6 axis)

Figure 15. **How the tracings should look like in the differ-
ent limb leads (generally should be more positive deflec-
tions)
AVR
 Since positive deflections are on the lateral and inferi-
Figure 13. Conventional grouping of limb leads or side, AVR is on opposite side away from the elec-
trode so it shows more of a negative deflection.
 Lateral Leads - Leads I and AVL, because each has a  Only exception is AVR because all other limb leads are
positive electrode positioned laterally on the left arm. towards the electrode causing positive deflection.
 Inferior Leads - Leads II, III and AVF, because each of
these leads has a positive electrode positioned inferiorly Chest Leads
on the left foot.  Electrodes placed on the chest; also unipolar,
heart is negative pole
 Lies in the horizontal/transverse plane, perpen-
dicular to the frontal plane of the limb leads.

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 4.7 Introduction to Electrocardiogram
Figure 16. Chest Leads in Horizontal plane
Figure 17. Expected appearance of chest leads in the ECG
 V1, V2 – more negative deflection because located
away from the direction of the impulse
 V3 – sometimes negative or equiphasic (upward is equal
to the downward)
 V4, V5, V6 – more positive deflection
Figure 18. Right and Left Chest leads
 V1, V2 – “right” chest leads; oriented over the right
side of the heart (right ventricle).
 V5, V6 – “left” chest leads; oriented over the left side
of the heart (left ventricle).
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Figure 19. Chest leads in the interventricular septum
 V3, V4 – oriented over the interventricular septum;
V3 nearer the right ventricle, V4 nearer the left ven-
tricle.
Figure 20. Setup of placing chest leads
HORIZONTAL AXIS
 Landmark for placing the chest leads: Angle of Louis
on the 2nd intercostal space (from the Angle of Louis,
count 2 intercostal spaces below it, which will be the
4th ICS).
 V1 – right border of sternum at 4th ICS
 V2 – left border of sternum at 4th ICS
 V3 – in between V2 and V4
 V4 – midclavicular line (left clavicle) at 5th ICS
 V5 – on anterior axillary line at 5th ICS
 V6 –on mid-axillary line at 5th ICS
 V5 and V6 placed along the plane of V4
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 4.7 Introduction to Electrocardiogram
 V3R – V3 on the right chest  Interval
 V4R – V4 on the right chest  Indicate time periods
 Measured in SECONDS on horizontal scale
NOTE: Where you can only find negative deflections (all  Waveform + Segment
others positive):  Complex
V1 and V2  Several waveforms
Sometimes V3
AVR
**Given an ECG, 1st thing to do is to look if the elec-
trodes are correctly placed, if it’s correctly placed it should
produce the characteristic positive and negative deflections for
each lead.

Figure 22. Complete graph of waveforms

 J point
 End of S wave and start of ST segment (QRS
complex ends).
 Exact point at which the wave of depolarization
Figure 21. ECG COLOR CODED LEADS just completes its passage through the heart
 Tells you the start of repolarization (Jacinto,
Standard 15-Lead ECG 2017).
 Seen elevated in pathologic cases.
 Anterior part of heart – by looking at V1-V4
 P wave
& V3R, V4R
 First deflection
 Lateral view of heart – I, AVL, V5, V6, &
 "Atrial deflection” (Atrial depolarization)
V7
 Represents the electrical activity
 Inferior view of heart – II, III, & AVF
(depolarization) of both atria and the simulta-
Waveform, Segment, Interval & Complex neous circulation of the atria
 Reflects the depolarization of the right and left
 Waveform atrial muscle.
 Movement away from the baseline to either + or -  Caused by electrical potentials generated when
 Segment the atria depolarize before atrial contraction
 Part of ECG where the tracing is expected to be begins.
relatively flat
 Measured in VOLTAGE on vertical scale
 Appearance of segment indicates no electrical
activity or deflection or minimal electrical activity
is present

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 4.7 Introduction to Electrocardiogram
 S Wave - negative deflection after the R wave
 No wave on the ECG while atria are repolarizing
because of the domination of strong electrical
activity from depolarization of the ventricles.
 QT Interval
 Beginning of QRS to end of T
 Time interval from the beginning of depolariza-
tion to the end of repolarization
 Measures the “TOTAL VENNTRICULAR ACTIVITY”.
 Should not exceed 1/2 the length of the RR.
Figure 23. P Wave
NOTE: There is no ECG wave that represents atrial repolarization
because atrial repolarization occurs simultaneously with ven-
tricular depolarization.
 PR Segment
 Between end of P wave and start of next wave
(QRS complex).
 Duration of conduction from the AV node, down the
bundle of His and through the bundle branches.
 Physiological delay due to conduction through AV
node prior ventricular depolarization. Figure 24. QRS Complex
 PR Interval
 From the beginning of P to the beginning of the 
QRS complex.
 Duration of impulse conduction from the SA node
to the AV node
 Normal PR Interval: 0.12-0.19 seconds, 0.16
seconds
 Interval is prolonged when there are circuit con- Figure 25. Q wave
duction blocks in the pathway (from AV node to
Purkinje fibers) 
 Beginning of excitation of atria and ventricles.
 QRS Complex
 “Ventricular depolarization”
 Time interval for impulse to go from AV node to
stimulate Purkinje fibers.
 Normal: 0.06-0.10 seconds
 Caused by potentials generated when the ventri-
cles depolarize before contraction, that is, as the
depolarization wave spreads through the ventri-
Figure 26. R wave & S wave
cles
 Q Wave – first downward wave of the QRS complex and
after P wave, may not be recorded, there is a rightward
spread of action potential
R Wave - first positive deflection after P wave
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 4.7 Introduction to Electrocardiogram
 RR Interval  As a simple rule of thumb, the QT interval is
 Time between QRS complexes considered normal when it is less than half of
 Duration of ventricular cycle the R-to-R interval at normal rates.
 Ventricular rate: used to compute for the heart
rate
 ST Segment
 Typically flat, isoelectric (goes back to zero)
 Represents the interval between ventricular depo-
larization and repolarization.
 If elevated or depressed, may imply pres-
ence of Myocardial Infarction

Figure 28. QT interval

 U wave
 Not very significant unless they are diffused:
may indicate Hypokalemia
 “After-depolarizations” in ventricle
 Repolarizations of Purkinje fibers/papillary
muscles.
Figure 27. ST wave  If U wave follows a normally shaped T wave, it
 T wave can be assumed to be normal. If it follows a
 “Repolarization wave” or “Ventricular repolari- flattened T wave, it may be pathological.
zation”
 Usually same vector as QRS
 Caused by potentials generated as the ventricles
recover from the state of depolarization
 Represents the final, “rapid” phase of ventricular
repolarization, during which ventricular repolari-
zation occurs quickly and effectively
 Normal: 0.25 to 0.35 seconds after depolariza-
tion
 QT Interval
 Measures the TOTAL VENTRICULAR ACTIVITY
(ventricular depolarization + ventricular repolarization)
 Normal: 0.26-0.40 seconds
 Duration varies with heart rate, sex, and age that
why we use formula to correct:

 Patients with hereditary Long QT interval (“LQT”)

syndromes are vulnerable to dangerous or even
deadly rapid ventricular rhythms.
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 4.7 Introduction to Electrocardiogram
PARTS OF an ECG TRACING  Example:
 5 big squares
1. P wave – Atrial depolarization Rate = 300 ÷ 5 = 60 bpm
2. Q wave – Initial negative deflection (Septal depolariza-
tion)
3. R wave – first positive deflection
4. S wave – negative deflection following R wave
5. QRS – Ventricular depolarization
 T wave – Ventricular repolarization
Assessing the Heart Rate
 HEART RATE
 Also known as the pulse
 Pacemaker: SA node (60-100 beats per min)
< 60: Bradycardia
> 100: Tachycardia
 May depend on the individual’s age, body size,
heart conditions, sitting or moving, medications,
temperature and even emotional status
 Can be observed through auscultation, palpita-
tions or using ECG

NORMAL HEART RATE RANGE BY AGE  RATE: Method 2 (R-R Interval of Small
Squares)
 Using lead II or the lead with the least artifact.
 Count the number of small squares between
two R waves.
 Heart rate:
1500 ÷ (# of small squares)
1 big squares = 5 small squares
Example:
5 big squares x 5 small squares = 25
small squares
Rate = 1500 ÷ 25 = 60 bpm
Figure 29. Changes can be accounted for by the gradual in-
crease in vagal tone that accompanies aging. RHYTHM
 DETERMINE THE RATE & RHYTHM  Normal sinus rhythm is the normal rhythm of the
 RATE: Method 1 (R-R Interval of Big heart.
Squares)  The rate is regular and between 60 and 100
 Using lead II or the lead with the least artifact. beats per minute.
 Count the number of big squares between two R  A heart rate above the upper limit of normal
waves. originating from the SA node is SINUS TACHY-
 Heart rate: CARDIA
 300 ÷ (# of big squares)  Sinus tachycardia is physiologic or appro-
priate when a reasonable stimulus, such
as secretion of cathecolamines due to
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 4.7 Introduction to Electrocardiogram
 fright, stress, or physical activity can pro-
duce tachycardia.
 A heart rate below the lower limit of normal origi-
nating from the SA node is SINUS BRADYCAR-
DIA
 Depolarization originates spontaneously within the SA
node (pacemaker of the heart).
 Regular atrial and ventricular rhythm, P-P interval & R-R
interval, respectively.
RELATIONSHIP OF BODY TEMPERATURE
TO HEART RATE
 Increased body temperature = increased in heart rate,
sometimes as fast as double normal.
 Directly proportional relationship
 Increased BT = increased HR
 Decreased BT = decreased HR Sinus Arrythmia
 These effects presumably due to the fact that heat in-  Normal, but extremely minimal, increase in
creases the permeability of the cardiac muscle mem- heart rate during inspiration, and an extremely
brane to ions that control heart rate, resulting in acceler- minimal decrease in heart rate during expira-
ation of the self-excitation process. tion.
 As your body heats up, the vessels near the skin dilate to  Longest RR interval is 0.08 longer than the
release heat. This causes reduced blood pressure, so the shortest RR interval.
heart must beat faster to compensate, and ensure blood
DETERMINATION OF SINUS RHYTHM
Normal Sinus Rhythm
 Particular strip represents a continuous recording
of Lead II in a patient with normal sinus rhythm. Non-sinus Rhythm
 Narrow QRS complex  Sinus rhythm is not present if the P wave is
 PR interval is regular but not necessarily regular negative lead II & AVF but positive in AVR.
 SA node – located in the right upper part of the  This pattern may be consistent with a
atrial mass. nonsinoatrial-atrial rhythm, such as
 Direction of atrial depolarization is from the right when the intrinsic cardiac pacemaker is
upper part towards the lower left part, resulting P in the low right atrium or in left atrium.
axis in the lower left quadrant (0 to +90 degrees.
Sinus Rhythm EVALUATION OF P-R INTERVAL
 PR Interval
 Positive P wave precedes the QRS complex.  If the PR interval is short (<3 small squares) it
 Normal P axis (0 to +90 degrees). may signify that there is an accessory electrical
 Upright or positive P waves in I, II, & AVF pathway between atria & ventricles, hence it
 Inverted or negative P waves in AVR causes the ventricles to depolarize early giving
 PR interval is consistent throughout the tracing. a short PR interval.

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 4.7 Introduction to Electrocardiogram
 Example is Wolff Parkinson White Syndrome

 If PR interval looks as though it is widening every

beat and then a QRS complex is missing, there is 2 nd
degree heart block (MOBITZ TYPE I).

 If the PR interval is constant but then there is a

missed QRS complex, there is 2nd degree heart block
(MOBITZ TYPE II).

 THE PR INTERVAL
 If the PR interval is long (>5 small squares or
0.20s) and RESULTS TO AV BLOCK.
 If there is a constant long PR interval: 1 st degree
heart block is present

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 4.7 Introduction to Electrocardiogram
hypocalcemia
myocarditis
diffuse myocardial diseases
head injury
severe malnutrition
antiarrhythmics
Prolonged QT interval antipsychotic phenothiazines
is associated with tricyclic antidepressants
antibiotics (e.g., ampicillin,
erythromycin, trime-
thoprim-sulfa)
Shortened QT interval digitalis toxicity,
is associated with hypercalcemia

 If PR interval has no discernable relationship between P

waves and the QRS complex, there is 3rd degree heart
block.
 The VR rate is low & atrial rate is normal.

INTERVALS & COMPLEXES  P wave

 QT interval
 use for diagnosing Atrial hypertrophy
 Varies with rate
 Normal P wave amplitude: <3 mm
 Measured in Lead II
 Duration of P wave:
 QTc using Bazett’s formula
< 0.09 s in children
**Normal: <0.44 men & <0.44 women
< 0.07 s in infants

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 4.7 Introduction to Electrocardiogram
RIGHT ATRIAL ENLARGEMENT
 P Pulmonale
 Tall, Broad, and Peaked P wave (lead II)
 Leads to delayed activation of the right atrium
 Causes delayed activation and the subsequent polariza-
tion of the atria to occur simultaneously.
 Often result of Pulmonary Hypertension
***Other causes: Atrial septal defect, Severe tricuspid regurgita-  T waves
tion, Tricuspid stenosis, Ebstein’s anomaly
 Tall peaked T waves
LEFT ATRIAL ENLARGEMENT  Hyperkalemia
 LVH (of the “volume overload” type)
 P Mitrale
 Flat or low T waves
 Widened and Deeply Notched P wave (Lead II) or Deep
 Normal newborns or with Hyperthyroid-
biphasic P wave (Lead VI)
ism
 Leads to delayed activation of the left atrium
 Hypokalemia
 Causes prolonged depolarization and a prolonged P wave.
 Pericarditis
 associated with Mitral Valve Disease
 Myocarditis
 Myocardial ischemia
COMBINED ATRIAL HYPERTROPHY
 Combination of increased amplitude and duration of P
wave

 QRS complex
 use for diagnosing ventricular hypertrophy
 R waves: taller in the right precordial leads (i.e.,
V4R, V1, V2)
 S waves: deeper in the left precordial leads (i.e.,
V5, V6) in infants and small children.
 ST segment PREMATURE VENTRICULAR
elevation or a depression of the ST segment is

judged in relation to the PR segment as the base-
CONTRACTION
line  the heartbeat is initiated by Purkinje fibers in
 Abnormal in cases of: Pericarditis, Myocardial is- the ventricles rather than by the sinoatrial node
chemia or Infarction, Digitalis effect  May be perceived as a "skipped beat" or felt
as palpitations in the chest.

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 4.7 Introduction to Electrocardiogram
 Ventricles contract first and before the atria have opti- QRS AXIS
mally filled the ventricles with blood.  represents the net depolarization through the myocar-
dium and is worked out using the limb leads
(particularly Lead I and aVF)
 QRS axis outside normal ranges signifies abnormalities
in the ventricular depolarization process

 PVCs gas have the following features:

 Broad QRS complex (≥ 120 ms) with abnormal
morphology.
 Premature — i.e. occurs earlier than would be
expected for the next sinus impulse.
 Discordant ST segment and T wave changes.
Pediatric QRS
 Usually followed by a full compensatory pause.
 Retrograde capture of the atria may or may
not occur.
HEXAXIAL REFERENCE
 Convention to present the extremity leads of the 12 lead
electrocardiogram.
 Provides an illustrative logical sequence that helps inter-
pretation of the ECG.
***Note: The positive of lead aVR is actually at -150 degrees
and the positive of lead aVL is actually at -30 degrees.
 Normal QRS axis depending on age:
 Newborn: 30-135 degrees
 1 – 6 months: 10-135 degrees
 6mo – 3 yrs: 10-110 degrees
 >3 yrs: 0-90 degrees

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 4.7 Introduction to Electrocardiogram
Other Reference for Hexaxial Reference System:

If III, AVR is (-) + 15 degrees

If AVR is (-) + 45 degrees

If AVR AVL is (-) +75 degrees

If I, AVR AVL is (-) +105 degrees

If I, AVL is (-) +135 degrees

If I, II, AVL is (-) +165 degrees

If III, AVF is (-) - 15 degrees

If II, III, AVF, AVR - 45 degrees

If II, III, AVF - 75 degrees

If I, II, III, AVF - 105 degrees

REFERENCES:
 Berne & Levy Physiology
 Dra. Lapak’s PPT

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