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Medicine 4.2 2 Sem/A.Y. 2016-2017

Basic ECG and Arrhythmias
Visvanath E. Espaldon, M.D.,FPCP, FPCC January 9, 2017

OUTLINE § There is a spike which elicits

Basic ECG depolarization; depolarization means
A. Review that the cell becomes more positive
B. Wigger’s Cycle § sodium is positive, potassium is negative
C. Electrodes and Leads (That is according to the lecturer, but both
D. Hexaxial Reference System are actually cations/positive. The cell
E. Segments, Intervals, and ECG Grid becomes more positive because three
F. Disorders of Rate or Rhythm sodium ions are exchanged for only 2
G. Mean Electrical Axis potassium ions, causing a net gain of +1
Cardiac Arrhythmias charge intracellularly.)
H. Tachyarrhythmias § Corresponds to the R wave in the EKG
I. Bradyarrhytmias § Represented by the slow influx of the
2+
Ca ion. This is responsible for muscle
Lecturer Harrison’s (19th ed.) Phases contraction in the heart.
+ +
italicized & 1, 2, 3 § Efflux of Na and return of K into the cell
causes repolarization, represented in the
BASIC ELECTROCARDIOGRAPHY AND ARRHYTHMIAS EKG as the T wave.
+ 2+ +
Just know the movement of the Na , Ca , and K ions, the
A. REVIEW
action potential, and the tracing of the EKG.
• Electrocardiography
o Based on the movements of electric ions in the B. WIGGER’S CYCLE
cardiac cells
o Graphical representation of the electrical conduction
of the heart
o What you see on EKG paper is actually a
representation of the electrical conduction
+ +
o Movement of Na , K ions
• Review of concepts
o Intracellular cation: Potassium; Extracellular cation:
Sodium
o Movement of these ions elicits an activation or a
response producing electrical conduction and
contraction of the cells
PISO (Potassium: intracellular; Sodium: out/extracellular)

Figure 2. Graph of the Wigger’s Cycle. Atrial contraction is

represented by (a). Isovolumetric contraction is (b) although not
indicated in this figure. It is represented by the Q wave on the
EKG. Ventricular depolarization is (c). Memorize this; if you can
grasp this concept, you know half of the hemodynamic concepts
already.

Table 2. The Wigger’s Cycle. This represents the cardiac cycle

Wave/
Description Interval in
EKG
§ The first phase of the
Figure 1. The action potential and its corresponding waves
Atrial Wigger’s cycle
on the EKG/ECG. P wave
Contraction § Represented by a hump
(a) in Figure 2
ACTION POTENTIAL
§ There is no change in
volume but the heart
Table 1. Summary of the Action Potential
muscle is contracting
§ Resting phase Isovolumetric
§ Enough pressure is Q wave
Phase 4 § Sodium is extracellular and potassium is contraction
being generated to
intracellular; there is no movement of ions propel the blood
Phase 0 § Sodium moves intracellularly forwards into the aorta

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Medicine 4.2 Basic ECG and Arrhythmias
§ Ventricular STANDARD 12-LEAD EKG
depolarization means Limb Leads
enough electricity is • 6 extremity leads
Ventricular transmitted to generate • Records the potentials transmitted onto the frontal plane
R wave
depolarization muscle contraction o Standard Limbs: I, II, III
§ There is enough force to o Augmented Limbs: aVF, aVR, aVL
propel the blood into the
aorta Chest/Precordial Leads
§ Blood is sufficiently • 6 chest leads
emptied out of the left • Records the potentials transmitted onto the horizontal
ventricle, aortic valve plane
closure will occur,
Isovolumetric
signifying the start of T wave Table 3. Summary of Chest Leads
relaxation
isovolumetric relaxation V1
th
4 ICS, right parasternal border
§ No change in volume V2
th
4 ICS, left parasternal border
but the left ventricle V3 Between V2 and V4
continues to relax th
V4 5 ICS, left midclavicular line
*Isovolumetric relaxation or ventricular repolarization th
V5 5 ICS, left anterior axillary line
th
V6 5 ICS, left midaxillary line
C. ELECTRODES AND LEADS
• The leads an electrodes of an EKG are like cameras. They
D. HEXAXIAL REFERENCE SYSTEM
are looking at different angles of the heart. These
electrodes detect the tiny electrical changes on the skin • The hexaxial reference system, better known as the
that arise from the heart muscle's electrophysiologic Cabrera system, is a convention to present the extremity
pattern of depolarizing during each heartbeat leads of the 12 lead electrocardiogram that provides an
• The movement of the electrical conduction of the heart is illustrative logical sequence that helps interpretation of the
from the SA node (the pacemaker of the heart) to the ECG, especially to determine the heart's electrical axis in
atria to the AV node then the purkinje fibers down to the frontal plane.
the ventricles (i.e. It moves inferiorly, anteriorly, and • It combines leads I, II, and III, as well as the augmented
laterally) limb leads aVR, aVL, and aVF to calculate the heart's
• The 12-lead EKG has a total of 3 limb leads and 3 electrical axis in the frontal plane
augmented limb leads arranged like spokes of a wheel in
the coronal plane (vertical/frontal) and 6 precordial leads
that lie on the perpendicular transverse plane
(horizontal/chest leads)

Figure 5. Hexaxial reference system. This is where we get

our angles from when we talk about axis deviation (discussed
further in axis direction computation)
Figure 3. ECG limb leads (Left) and Chest leads (Right)
E. SEGMENTS, INTERVALS, AND ECG GRID

Figure 6. Components of an ECG tracing

Figure 4. Spatial orientation of EKG leads (Blue are limb
leads and Red are chest leads). Note how Lead II closely
mimics the normal pathway of conduction which is downward
and to the left, thus it is the most commonly used lead during
cardiac monitoring

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Medicine 4.2 Basic ECG and Arrhythmias
REMEMBER:
• Standard running rate of ECG: 25mm/sec
• Horizontal axis: measures time
o 1 Large box: 5 mm = 0.2 seconds
o 1 Small box: 1 mm = 0.04 seconds
• Vertical axis: measures voltage
o 1 Large box: 5 mm = 0.5 mV
o 1 Small box: 1 mm = 0.1 mV
TERMS USED IN AN ECG
• Wave: upward or downward deflection
• Complex: series of waves
• Segment: connection between 2 waves; or a complex and
a wave
• Amplitude: height of the wave/complex (in voltage)
• Interval: time it takes from wave to the next
PARTS OF AN ECG
Table 4. Summary of the parts of an ECG and Their Normal
Value
Wave Description
P wave § Represents atrial
depolarization (normal
vector points down and to
the left)
§ normal P wave: smooth squares
and rounded;
PR § Interval between atrial
interval depolarization and
ventricular depolarization
§ Necessary to allow for the < 5 small
filling of blood to the squares
ventricle. If they (atria and
ventricle) contract
simultaneously, filling will
not occur
R wave § Ventricular contraction
S wave § Beginning of ventricular
repolarization
QT § Gap between ventricular
interval contraction and
ventricular relaxation
§ Important when we study
arrhythmias because it
presents as QT
prolongation or QT
shortening causing
ventricular arrhythmias
§ It is needed to allow full
ventricular contraction
§ In cardiac musles, we
have an ‘all or none’
principle – contracted or
not at all – else we see
arrhythmias
QRS • From the beginning of < 0.12
interval ventricular depolarization seconds
to the end of ventricular OR
depolarization
• It is how long the ventricle squares
should contract
• May be prolonged in
cases of bundle branch
blocks
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STEPS IN READING AN ECG
1. Determine the Heart Rate
o Normal heart rate: 60 – 100 bpm
Equations:
HR = 300 / Number of big squares from 1 R wave to the
next R wave
OR
HR = 1500 / Number of small squares from 1 R wave to
the next R wave
2. Determine the Heart Rhythm
o The rhythm is either sinus rhythm or not sinus rhythm.
Sinus rhythm refers to the origination of the electrical
activity coming from the SA node which is located in
the upper part of the wall of the right atrium. This
results in an upright P and R wave in lead II, III, and
aVF on the ECG.
§ Other criteria for Sinus rhythm: There should
be 1 P before the QRS complex
§ How would you know that it came from the
right atrium? R wave should be upright in
Normal Lead II. This is also supported by Lead III
Value and aVF.
< 0.12 3. Measure the intervals: PR intervals PR segments and QT
seconds intervals
OR 4. Calculate the mean electrical axis
< 3 small 5. Analyze the different waves and segments (Are there
abnormalities in the P waves, QRS complex, the T or the U
waves?)
< 0.20
seconds F. DISORDERS OF RATE OR RHYTHM
OR Sinus tachycardia
• Sinus rhythm with resting heart rate > 100 bpm in adults,
or above the normal range for age in children
• Can be non-pathologic (due to emotions, caffeine intake,
and stimulation of sympathetic responses) in young
individuals. This is not treated but instead, the agent
causing this condition is withdrawn.
• Pathologic sinus tachycardia may be due to
overstimulation of thyroid hormone.
< 0.44 Sinus bradycardia
seconds • Sinus rhythm with resting heart rate < 60 bpm in adults, or
OR below the normal range for age in children
< 11 small
squares Sinus arrhythmia
• Sinus rhythm with a beat-to-beat variation in the P-P
interval (the time between successive P waves), producing
an irregular ventricular rate.
Atrial fibrillation
• Occurs when action potentials fire very rapidly within the
pulmonary veins or atrium in a chaotic manner. The result
is a very fast atrial rate (about 400-600 bpm). Because the
atrial rate is so fast, and the action potentials produced are
of such low amplitude that the P waves will no longer be
seen on the ECG in patients with atrial fibrillation.
• No defined P wave, just fibrillatory waves
< 3 small
Figure 7. Atrial Fibrillation
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Medicine 4.2 Basic ECG and Arrhythmias
G. MEAN ELECTRICAL AXIS OF THE HEART
• Mean orientation of QRS vector with reference to 6 frontal
plane leads (limb leads)
• Sum of all currents during ventricular depolarization
• Preponderant direction of the potential during
depolarization
• Range of the normal axis: -30 degrees to 90 degrees
(some, 100 degrees)
o This is where the movement of the electrical
current should be
• To determine the QRS axis, the limb leads (not the
precordial leads) need to be examined. The depiction of
the standard leads and their relationship to the cardiac axis
is below
o Normal: 0 to +90 degrees
o Left AD: 0 to -90 degrees
o Right AD: +90 to 180 degrees
o Extreme Axis Deviation: -90 to 180 degrees
o Determining the axis can be done by plotting 2
perpendicular leads (Lead I and aVF)
Figure 8. Mean Electrical Axis
STEPS IN DETERMINING THE AXIS
1. Measure the amplitude of leads I and aVF (2 perpendicular
leads)
2. Look at the QRS complex of the leads
3. Count the small squares occupied by the upward deflection
(+) of the QRS complex (how many squares does the R
wave reach) of the first lead
4. Count the small squares occupied by the downward
deflection (-) of the QRS complex of the first lead
5. Get the algebraic sum (note that the sign is positive for
upward and negative for downward deflections), and plot
on the axis of the lead
6. Do the same for the second lead
7. Determine the axis by looking at which quadrant of your
graph your plotted points are located
Example:
In Lead I, the difference between the upward and downward
deflection is 3 small squares. In aVF, the difference between
the upward and downward deflection is 5 small squares
Figure 9. Graph of the Example. The finding in Lead 1 (3
squares) was plotted on the x-axis, while the finding in aVF (5
small squares) was plotted on the negative y-axis. The resultant
vector forms a 60° with the x-axis. Mean electrical axis: 60°
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CARDIAC ARRHYTHMIAS
Note: Only a few additional info from Harrisons were included to
help us better understand the topic, but doc said to just focus on
what he discussed
H. TACHYARRHYTHMIAS
1. Sinus Tachyarrhythmia
• This is a sinus rhythm with an elevated rate of
impulses defined as a heart rate above 100 bpm
• To know that it originated from the sinus:
o P wave is upright
o R wave is upright
o T followed by QRS segment
& Sinus tachycardia typically occurs in response to
sympathetic stimulation and vagal withdrawal
& Taller P waves in the inferior limb leads when
compared to normal sinus rhythm are observed
Figure 10. Sinus Tachyarrhythmia
2. Atrial fibrillation
• Most common cardiac arrhythmia involving the atria
• No P wave but present fibrillatory waves
• Fibrillatory waves: indistinct waves that are not
represented by normal PQRS, but have a normal QRS
segment
o R to R interval is irregularly irregular
o No P wave
o Not followed by QRS
• Pathologic arrhythmia may be due to degeneration (in
elderly) or hypertensive cardiovascular diseases
& Atrial fibrillation is characterized by disorganized,
rapid, and irregular atrial activation with loss of atrial
contraction and with an irregular ventricular rate that is
determined by AV nodal conduction
Figure 11. Atrial Fibrillation
3. Atrial flutter
• Similar to atrial fibrillation (fibrillatory waves are finer),
but has a characteristic saw-toothed pattern.
• It is a pathologic arrhythmia and has the same
causes as atrial fibrillation
• Regular or normal R to R interval
Figure 12. Atrial Flutter
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Medicine 4.2 Basic ECG and Arrhythmias
Normally, the top chambers (atria) contract and push blood
into the bottom chambers (ventricles). In atrial fibrillation,
the atria beat irregularly. In atrial flutter, the atria beat
regularly, but faster than usual and more often than
the ventricles.
4. Supraventricular tachycardia
• This has a narrowed QRS segment compared to
ventricular tachycardia
• Rate goes as high as 200 bpm or more
• Has regular R to R intervals
• No distinct P wave
• Pathologic
• It can be seen in young patients with genetic rhythm
disorders (Wolff Parkinson White Syndrome) and
reentry problems (reentrant tachycardia)
From 2017B:
SVT is any tachycardic rhythm originating above the
ventricular tissue but not coming from the sinus, there is an
accessory pathway.
Figure 13. Supraventricular Tachycardia
5. Ventricular tachycardia
• Wide/bizarre-looking QRS complexes
• P and R waves are not clearly defined
• Pathologic
• Fatal
o If you encounter this and the patient is pulseless,
you initiate ECLS (extracorporeal life support)
o If patient has a pulse, electrical cardioversion may
be done
• This can be seen in patients with coronary artery
disease or heart failure. Patients with low ejection
fraction and low systolic functions are predisposed to
ventricular tachycardia
Figure 14. Ventricular Tachycardia
6. Ventricular fibrillation
• A severely abnormal heart rhythm (arrhythmia) that
can be life-threatening.
• Medical emergency: requires Basic Life Support
• Rate cannot be discerned, rhythm unorganized
• Chaotic electrical activity occurs with no ventricular
depolarization or contraction
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• The amplitude and frequency of the fibrillatory activity
can be used to define the type of fibrillation as coarse,
medium, or fine.
• There is no pulse or cardiac output. Rapid
intervention is critical. The longer the delay, the less
the chance of conversion.
Figure 15. Ventricular Fibrillation
I. BRADYARRHYTHMIAS
1. Sinus Bradycardia
• < 60 bpm
• May or may not be pathologic
o Non-pathologic sinus bradycardia
§ Ex: Athletes have well developed cardiac
function. They can manage to slow down
their heart thus having relatively slow
rhythm. This is a normal physiologic
response of the body when you have a very
good cardiac function.
o Pathologic Sinus Bradycardia
§ Drug Induced – we have a lot of medications
that can slow down the rhythm especially
those affecting the SA or AV node
ü Beta-blockers: block the AV node
ü Calcium channel blockers (i.e.
Verapamil)
ü K-channel blockers (i.e. Amiodarone)
2. AV Blocks
& These are usually diagnosed electrocardiographically,
which characterizes the severity of the conduction
disturbance
& It manifests as slow conduction or, if severe, failure to
conduct
st
1 Degree AV Block
& This is a slowing conduction through the AV junction
• May or may not be pathologic
• If Non-Pathologic:
o You can have normal patients (even young
st
patients) who have a 1 degree AV block. As
long as they are not symptomatic and they don’t
have any cardiovascular disease, it is
physiologically normal
• Manifested by the prolongation of the PR interval
• Normal PR interval: Up to 0.20 seconds (should not
exceed 1 big square)
• Usually does not warrant specific treatment
• If patients are asymptomatic, just withdraw the
causative agent or drug causing the block (you may
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Medicine 4.2 Basic ECG and Arrhythmias
advise the patient to shift from a beta-blocker to
another anti-hypertensive)
st
Figure 16. 1 degree AV block. P wave precedes each QRS
complex but PR intervals are prolonged and remain constant
from beat to beat, without drop.
nd
2 Degree AV Block
& There is an intermittent failure of electrical impulse
conduction from the atrium to the ventricle
• Always pathologic
• May be drug induced or due to a cardiovascular
disease
• Usually does not warrant treatment
• If patients are asymptomatic, just remove or withhold
the drug causing the AV block
• But if they are symptomatic (dizziness or syncope),
treatment would be to implant a pacemaker
nd
Two types of 2 Degree AV Block
1. Mobitz Type I (Wenckebach)
• Characteristic prolongation of the PR interval, followed
by a P and a dropped QRS
& Periodic failure of conduction is characterized by a
progressively lengthening PR interval, shortening of
the RR interval, and a pause that is less than two
times the immediately preceding RR interval on the
ECG
2. Mobitz Type II
• There is also a dropped QRS (dropped beat), but the
PR prolongation is constant
& Characterized by intermittent failure of conduction of
the P wave without changes in the preceding PR or
RR intervals
nd
Figure 17: 2 Degree AV block, Type I. You have a normal PR
which continually prolongs. You have a progressive prolongation
of your PR interval, and then suddenly you have a dropped beat
after a P.
nd
Figure 18. 2 Degree AV block, Type II. Normal PR interval
with sudden drop in QRS complex but still preceded by a P
wave. QRS complexes are usually wide because this block
usually involves both bundle branches
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rd
3 Degree AV Block
• Complete failure of conduction from atrium to ventricle
• Always pathologic
• Normal P to P interval and a normal R to R interval,
but the interval of the P and R waves are different
• The R to R interval (RR) are constant; they are equal
in length. The P waves, the P to P interval (PP) are
also constant - they are also equal. But the duration of
the PP is different from the duration of the RR. RR
interval is usually greater than the PP interval
• Treatment: Pacemaker – it is the only treatment for
rd
3 degree AV blocks
rd
• When you see patients with a 3 degree AV block,
even if they are asymptomatic, always advise them to
have pacemaker implantation.
rd
Figure 19: 3 degree heart block. P waves are normal (upright
and uniform), but may be superimposed on QRS complexes or T
waves.
In general, bradyarryhthmias may cause syncope or
dizziness because of the insufficiency of blood flow to your
cerebral circulation
GUIDE QUESTIONS
1. The ECG showed a maximal positive deflection in Lead II
while the aVL showed an equiphasic deflection. The axis of the
electrical activity is proably:
a.) Zero degree
b.) Plus thirty degrees
c.) Plus sixty degrees
d.) Minus thirty degrees
Ans: C. It is perpendicular to aVL, aVL is -30 degrees. Lead II
therefore must be at +60 degrees.
2. P waves in Lead II are negative. The source of electrical
activity in the heart must be:
a.) The sinus
b.) High in the right atrium
c.) The AV node
d.) The right ventricle
Ans C. SA node is in the junction of the SVC and RA. From the
AV node, electrical activity will travel upwards to depolarize the
atria, it will record deflections in Lead II.
3. PR interval on ECG represents:
a.) The time it travels by which electrical activity in the heart
travels from the atria to the Purkinje fibers
b.) The time interval required to pass the AV node
c.) The time interval required to conduct through the atria and
the AV node
d.) The time interval required to depolarize the entire heart
Ans A. QRS is ventricular depolarization. The PR interval
therefore would be from atria up to just before the ventricles are
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Medicine 4.2 Basic ECG and Arrhythmias
depolarized. SA nodal electrical activity is not picked up in the 9. What is the type of AV block in the tracing below?
ECG.

4. What is the HR

a.) First degree

b.) Second degree type 1
c.) Second degree type 2
d.) Complete heart block

9. Identify the rhythm abnormality below

a.) 75
b.) 60
c.) 50
d.) 40
a.) Sinus tachycardia
b.) Junctional tachycardia
Ans C. 300/6 big squares= 50bpm
c.) Ventricular tachycardia
d.) Ventricular fibrillation
5. What is the PR interval
10. Identify arrhythmia below

a.) Sinus tachycardia

b.) Atrial fibrillation
c.) Atrial tachycardia
d.) Atrial flutter

a.) 0.16 sec. REFERENCES

b.) 0.20 sec. 1. Lecture recording
c.) 0.28 sec. 2. Cardiac axis in 5min:
d.) 0.32 sec. https://www.youtube.com/watch?v=_CCUWdAaQoA
3. Hexaxial reference system:
6. What is the rhythm https://www.youtube.com/watch?v=mXSZss6x8os
4. Harrison’s Principle of Internal Medicine (PP: 1983, 1998,
2015, 2021)

a.) Sinus
b.) Junctional
c.) Ventricular
d.) Pacemaker

7. Identify the arrhythmia in the following tracing:

a.) Atrial flutter

b.) Ventricular fibrillation
c.) Atrial fibrillation
d.) Ventricular fibrillation

8. What is the rhythm in the following tracing

a.) Atrial flutter

b.) Ventricular flutter
c.) Atrial fibrillation
d.) Ventricular fibrillation

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