ECG BASICS

Dr. Muhammad Sayadul Bashar

Medicine unite- 1 SBMCH
Assistant Registrar

 An ECG is a series of

waves and deflections recording the hearts electrical activity from a certain view. It is the graphic tracing of electrical activities of heart.

The The conduction conduction system system

Paper-

1 small sq = 1mm =0.04 sec 1 large sq = 5mm = 0.2 sec paper speed 25mm/ sec = 5 large sq/ sec 15 large sq =3 sec, 30 large sq =6 sec 1mv =10mm (10 small sq vertically)

Recording of the ECG

Standard calibration signal

Leads-

12 conventional leadsa)Frontal plane leads- 6 i)Standard leads- I, II, III ii) Augmented leads- aVR, aVL, aVF b) Horizontal leads- 6 Precordial leads- V1 V6
V stands for unipolar leads Unipolar limb leads- aVR, aVL, aVL Unipolar chest leads V1 V6 Augmented unipolar limb leads (aVR, aVL, aVL) are oriented to or face the heart from the root of limbs.

 Vertical and

horizontal perspective of the leads. The limb leads view the heart in the vertical plane and the chest leads in the horizontal plane

 aVF and aVL are

in the same frontal plane. The chest leads encircle the left thorax in a horizontal plane.

 Voltage changes are amplified and visually

displayed on an oscilloscope and graph paper. An ECG tracing looks different in each lead because the recorded angle of electrical activity changes with each lead. Several different angles allow a more accurate perspective than a single one would. A cable attached to the patient is divided into several different- colored wires: three, four, or five for monitoring purposes, or ten for a 12-lead ECG. Incorrect placement of electrodes may turn a normal ECG tracing into an abnormal one.

Electrodes are placed on the right arm (RA), left arm (LA), right leg (RL), and left leg (LL). With only four electrodes, six leads are viewed. Standard leads: I, II, III Augmented leads: aVR, aVL, aVF

Standard limb leads I, II, and III

Augmented Limb Leads

V1

4th intercostal space at right sternal border

4th intercostal space at left sternal border Midway between V2 & V3 lead on the left side 5th intercostal space in left midclvicular line 5th intercostal space in left anterior axillary line

V2

V3

V4

V5

V6

5th intercostal space in left midaxillary line

The Right-Sided 12-Lead ECG

The limb leads are placed as usual but the

chest leads are a mirror image of the standard 12-lead chest placement. The ECG machine cannot recognize that the leads have been reversed. It will still print V1V6 next to the tracing. Be sure to cross this out, and write the new lead positions on the ECG paper.

Patients with an acute inferior MI should have right-sided ECGs to assess for possible right ventricular infarction.

Vertical Versus Horizontal Heart Position

Both aVR and aVL face the ventricular cavity

and show a QS complex. A qR complex in lead aVL indicates a horizontal heart position, and the QRS morphology in aVL resembles that in V5. A qR complex in aVF and a QS complex in aVL indicate a vertical heart position, and the QRS morphologies in leads aVF and V5 resemble each other. The position of the heart varies between horizontal and vertical.

Changes in deflections with the heart in a vertical (A) and a horizontal (B) position

Variations in the normal precordial QRS configuration and correlations with abnormals

Sodium influx, potassium efflux, the action potential, and the ECG
(From Khan, M. Gabriel: On Call Cardiology, 3rd ed., Philadelphia, 2006, WB Saunders, Elsevier Science)

Normal 12-Lead ECG

Artifact
Artifacts are ECG deflections caused by influences other than the heart's electrical activity.

Loose Electrodes

Baseline Varies with Respiration

60-Cycle Interference

Muscle Artifact

Electrical Components

P wave

 The P wave upright in all leads but inverted in lead

aVR. Sinus P waves are usually most prominently seen in leads II and V1.

Absent P wave -Atrial fibrilation -SA block -AV nodal rhythm -Ventricular ectopics & VT - Hyperkalaemia Tall P wave Tall P is called P pulmonalle due to right atrial hypertrophy or enlargement. Small p wave -Atrial tachycardia -Atrial ectopic -Nodal ectopic

Wide P wave P wave is broad and notched call P mitrlle (duration >0.11 sec or >2.5 small sq) due to left atrial hypertrophy or enlargement. In V1 Pwave may be biphasic with a small positive wave preeceding a deep and broad negetive wave (indicate left atrial enlargement or hypertrophy). Inverted P wave ( negetive in LI, LII, aVF ) -Incorrectly placed lead -Dextrocardia -Nodal rhythm with retrograde conduction Variable P wave in wandering pacemaker.

PR interval
Distance between the onset of P wave to the beginning of QRS complex. Normally 0.12 sec 0.2 sec(3-5 small sq)

Prolong PR intervale 1 heart block due to -IHD -Acute rhumatic carditis -Hypokalaemia -Digitalis toxicity, Quinidine, ocatinally Beta blocker, Verapamil. Small PR intervale -WPW syndrome (presence of delta wave) -Lown Ganong Levi syndrome (no delta wave) -Nodal rhythm -A dissociated beat. Variable PR intervale -2 heart block - CHB

QRS complex

Einthoven labeled the waves P, Q, R, S, and T; his lettering obeyed the convention used by geometricians.

Q wave
first negetive deflection of QRS complex. Small Q wave usually present in aVL, V5, V6 but <2mm dedth (25% in amplitude of following R wave). Pathological Q wave Depth >2mm(2 small sq), Wide >0.4 sec (>1 mm). Should be present in more than 1 lead. Q wave should be >25% of the following R wave. Cause-Myocardial Infarction -Cardiomyopathy -LBBB -Q only in Lead III is associated pulmonary embolism.

R wave

It is the first positive upward deflection due to ventricular depolarization. Duration <0.01 sec Usually small in V1 & V2. It increase progressively in height in V3 to V6. Normal height of R waveaVL- <13mm aVF- <20mm V5 & V6- <25mm Tall R wave Left ventricular hypertrophy (in V5 or V6 >25mm, aVL >13mm, aVF >20mm) In V1 tall R may be due to-RVH -True posterior MI -WPW syndrome -RBBB -Dextrocardia

Small R wave -incorrect ECG calibration -Obesity -Pericardial effusion -Hypothyroidism -Hypothermia R wave progression The height of R wave gradually increase from V1 to V6, is called R wave progression. Poor progression of R wave In poor R wave progression, amplitude of R wave is progressively reduced in V5 & V6. -Anterior or Anteroseptal MI -LBBB -Dextrocardia -Cardiomyopathy

S wave

It is the negative deflection after R wave (1/3 of R wave). Normally deep in V1 & V2, progressively diminished from V1 to V6. In V3 R & S waves are almost equal.

QRS
QRS is predominantly positive in LI, aVL, V5 & V6. High voltage QRS -Increase calibration -Thin chest wall -Ventricular hypertrophy -WPW syndrome -True post MI (V1& V2) Low volatge QRS (<5mm in LI, LII, LIII & <10mm in chest lead) -Incorrect calibration -Obesity -Hypothyroidism -Emphysema -Pericardial effusion -Hypothermia

Wide QRS (>3 small sq) -Bundle branch block -Ventricular ectopics -Ventricular tachycardia -Hyperkalaemia -WPW syndrome -quinidine, TCA, Phenothiazin. Change shape of QRS -BBB -VT -VF - Hyperkalaemia

Variation in QRS wave form

ST segment

End of the S wave to the beginning of Twave.

Represent ventricular repolarization. Normally in isoelectric line. ST elevation is normal up to 1mm in limb lead, 2mm in chest leads. Normally ST segment may be depressed, but <1mm.

ST elevation (>2mm) -Recent MI(convexity upward) -Acute pericarditis (concavity upward) -Prinzmetal angina -Ventricular aneurysm (persitant) -Early repolarization ( high take off) ST depression -Acute myocardial ischemia (horizontal or down slope, ST depression with sharp angle ST-T junction) -Ventricular hypertrophy with strain -Digoxin toxycity (thumb impression) -Acute true post MI (V1 & V2)

T wave
Represent ventricular repolarization. Upright in all leads except aVR. May be normally inverted in V1 & V2. Normally not more than 5mm in standard leads & 10mm in chest leads.

Tip of T is smooth.

T wave inversion -Myocardial ischemia or infarction -Subendocardial MI -Ventricular ectopics - Ventricular hypertrophy with strain - Acute pericarditis -BBB -Physiological (smoking, anxity, anorexia,exercise, after meal) Tall peaked T - Hyperkalaemia -Hyperacute MI Small T wave -Hypokalaemia -Hypothyroidism -Pericardial effusion

QT interval
The QT interval is
measured in lead aVL as this lead does not have prominent U waves. Normally 0.35-0.43 sec. Normally does not exceed half the preceding R-R intervale. The QT interval is measured from the beginning of the QRS complex to the end of the T wave. It represents the total time taken for depolarisation and repolarisation of the ventricles.

Short QT -Digoxin effect -Hypercalcaemia -Hyrethermia -Tachycardia Long QT -hypocalcaemia -Bradycardia -Acute myocarditis -AMI -Hypothermia -Cerebral injury (Head injury, ICH) -Hypertrophic cardiomyopathy.

U wave
The U wave is a small

deflection that follows the T wave. It is generally upright except in the aVR lead and is often most prominent in leads V2 to V4. Normal ampletude 1mm Inverted U IHD, LVH strian Prominent U waves may be found in athletes and are associated with hypokalaemia and hypercalcaemia.

Methods for Calculating Heart Rate

Regular rhythms can be quickly determined
by counting the number of large graph boxes between two R waves. That number is divided into 300 to calculate bpm. The rates for the first one to six large boxes can be easily memorized. Remember: 60 sec/min divided by 0.20 sec/large box 300 large boxes/min.

Method 1: Count Large Boxes

Counting large boxes for heart rate. The rate is 60 bpm.

Method 2: Count Small Boxes

Sometimes it is necessary to count the number of small Boxes between two R waves for fast heart rates. That number is divided into 1500 to calculate bpm. Examples: If there are six small boxes between two R waves: 1500/6 250 bpm. If there are ten small boxes between two R waves: 1500/10 150 bpm.

Clinical Tip: Approximate rate/min is rounded to the next highest number.

Method 3: Six-Second ECG Rhythm Strip

The best method for measuring irregular rates with varying R-R intervals is to count the number of R waves in a 6-sec strip and multiply by 10. This gives the average number of bpm. Clinical Tip: If a rhythm is extremely irregular, it is best to count the number of R-R intervals per 60 sec (1 min).

Electrical Axis of the Heart

The electrical axis is
the sum total of all electrical currents generated by the ventricular myocardium during depolarization. The direction of the QRS complex in leads I and aVF determines the axis quadrant in relation to the heart.

Left axis deviation

-Normal veriant -LVH -LBBB -Inferior MI -WPW syndrome -Emphysema -Endocardial pacing

Right axis deviation

-Normal veriant -Anterolateral MI -Dextrocardia -WPW syndrome -RBBB -Epicardial pacing

Left axis deviation

Left axis deviation

Right axis deviation

Right axis deviation

ECG Interpretation

 Clinical Tip: Sinus tachycardia may be caused by exercise, anxiety, fever, hypoxemia, hypovolemia, or cardiac

 Clinical Tip: Cardiac output may decrease, causing syncope or dizziness.

Sinoatrial (SA) Block

R Wave Progression

Normal ventricular

depolarization in the heart progresses from right to left and from front to back. In a normal heart the R wave becomes taller and the S wave becomes smaller as electrical activity moves across the heart from right to left. This phenomenon is called R wave progression. Alteration in the normal progression of the R wave may be seen in left ventricular hypertrophy, COPD, left bundle branch block, or anteroseptal MI.

Left Ventricular hypertrophy

ECG criteria -R in V5 or V6 >25mm -R in V5 or V6 + S in V1 >35mm -R in aVL >11mm -R in aVF >20mm -R in LI >15mm -Sum of all QRS in all 12 leads >175mm -Left axis deviation

Causes -Systemic hypertension -Aortic stenosis -Coarctaion of aorta -Hypertrophic cardiomyopathy -VSD, MR, AR, PDA -Coronary artery disease

Right Ventricular hypertrophy

ECG criteria -tall R in V1 (>7mm) also deep S in V5 or V6 -R in V1 + S in V5 or V6 10.5mm -R in aVR >5mm -Right axis deviation Causes -Chronic corpulmonale -Pulmonary hypertension -Pulmonary stenosis -Eisenmengers syndrome -ASD, VSD, TR

Left Bundle Branch Block

-M pattern (RSR) in V5 & V6, also in LI & aVL. -There may W pattern in V1 & V2 -QRS wide, >0.12sec (3small sq)

Causes -Sever coronary artery disease (2or 3 vessels disease) -AMI -Cardiomyopathy -LVH -Hypertension -Myocarditis

Right Bundle Branch Block

-M pattern (RSR) in V1 & V2, also in LI & aVL. -QRS wide, >0.12sec (3small sq) -Broad, deep S in V5 & V6 (also in LI & aVL )

Causes -Normal varient -Coronary artery disease -RVH -Chronic copulmonale -pulmonary embolism -Cardiomyopathy -Conduction system fibrosis

Atrial Arrhythmias
P Waves differ in appearance from
sinus P waves. QRS Complexes are of normal duration.

Wandering Atrial Pacemaker (WAP)

Multifocal Atrial Tachycardia (MAT)

Clinical Tip: MAT is commonly seen in patients with COPD but may also occur in acute MI.

Premature Atrial Contraction (PAC)

Clinical Tip: In patients with heart disease, frequent PACs may precede paroxysmal supraventricular tachycardia, atrial fibrillation, or atrial flutter.

Atrial Tachycardia

Supraventricular Tachycardia (SVT)

Clinical Tip: SVT may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.

Paroxysmal Supraventricular Tachycardia (PSVT)

Clinical Tip: The patient may feel palpitations, dizziness, lightheadedness, or anxiety.

Atrial Flutter

Atrial Fibrillation

Wolff-Parkinson-White (WPW) Syndrome

Clinical Tip: WPW is associated with narrow-complex tachycardias, including atrial flutter and atrial fibrillation.

Junctional Arrhythmias

Accelerated Junctional Rhythm

Junctional Tachycardia

Junctional Escape Beat

Premature Junctional Contraction (PJC)

Ventricular Arrhythmias
QRS complex is >0.10 sec. P waves are absent or, if visible, have no
consistent relationship to the QRS complex.

Idioventricular Rhythm

Clinical Tip: Idioventricular rhythm may also be called agonal rhythm.

Premature Ventricular Contraction (PVC)

Usually PVCs result from an irritable ventricular focus. PVCs may be uniform (same form) or multiform (different form) The pause following a PVC may be compensatory or
noncompensatory.

Premature Ventricular Contraction

Ventricular Tachycardia (VT): Monomorphic

QRS complexes in monomorphic VT have the same shape and amplitude. It is important to confirm the presence or absence of pulses because
monomorphic VT may be perfusing or nonperfusing. Monomorphic VT will probably deteriorate into VF or unstable VT if sustained and not treated.

Clinical Tip: Torsade de pointes may deteriorate to VF or asystole. Frequent causes are drugs that prolong QT interval and electrolyte abnormalities such as hypomagnesemia.

Electromechanical Dissociation (EMD) or Pulseless Electrical Activity (PEA)

Hyperkalaemia
ECG criteria -P: wide, small, ultimately absent -PR interval prolonged -QRS wide, slurred and bizarre -T: tall, peaked and tented (in chest lead)

Hypokalaemia
ECG criteria -U prominent in chest lead -ST depression, T is small or inverted, prolonged PR interval.

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