Basics of

Electrocardiography

What is an ECG?
An ECG is the recording (gram)
of the electrical activity(electro)
generated by the cells of the heart(cardio)
that reaches the body
surface.

Recording ECG
William Einthoven

Useful in diagnosis of
Cardiac Arrhythmias
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances
Drug effects and toxicity

Recording an ECG

Basics
ECG graphs:
1 mm squares
5 mm squares
Paper Speed:
25 mm/sec standard
Voltage Calibration:
10 mm/mV standard

ECG Paper: Dimensions

5 mm
1 mm

0.1 mV

0.04 sec
0.2 sec

Speed = rate

Voltage
~Mass

ECG Leads
The standard ECG has 12 leads:

3 Standard Limb Leads

3 Augmented Limb Leads
6 Precordial Leads

The axis of a particular lead represents the viewpoint from

which it looks at the heart.

Summary of Leads

Bipolar

Limb Leads

Precordial Leads

I, II, III

(standard limb leads)

Unipolar

aVR, aVL, aVF

(augmented limb leads)

V1-V6

Anatomic Groups
(Summary)

Interpretation of an ECG

Steps involved
Heart Rate
Rhythm
Axis
Wave morphology
Intervals and segments analysis
Chamber enlargement
Specific changes

Wave forms

Cardiac Conduction: Cycle

Initiation

Cardiac Conduction: P Wave

Cardiac Conduction: AV Node

Cardiac Conduction: Bundle

Branches

Cardiac Conduction: Purkinje

Fibers

Cardiac Conduction: QRS

Complex

Cardiac Conduction: Plateau

Phase

Cardiac Conduction: T-Wave

Label the ECG

P Wave:

Atrial Depolarization.

Can be positive, biphasic, negative.

QRS Complex: Ventricular Depolarization.

Q Wave: 1st negative deflection wave before R-Wave.
R Wave: The positive deflection wave.
S Wave: 1st negative deflection wave after R wave.

T Wave:

Ventricular Repolarization.

Can be positive, biphasic, negative.

Calculating Heart Rate

1) Measure Cycle Length (CL).
1) (# small boxes from R R) (40ms) = CL .

2) Calculate HR

60,000/CL = x BPM
(20)(40ms) = 800ms
60,000/800 = 75 bpm

(25)(40ms) = 1000ms
60,000/1000 = 60 bpm

(12)(40ms) = 480ms
60,000/480 = 125 bpm

Calculating the Heart Rate

The Rule of 300
# of big
boxes

Rate

300

150

100

75

60

50

The QRS Axis

The QRS axis represents the net overall
direction of the hearts electrical activity.
Abnormalities of axis can hint at:
Ventricular enlargement
Conduction blocks (i.e. hemiblocks)

The QRS Axis

By near-consensus, the
normal QRS axis is defined
as ranging from -30 to +90.

-30 to -90 is referred to as a

left axis deviation (LAD)

+90 to +180 is referred to as

a right axis deviation (RAD)

Determining the Axis

The Quadrant Approach
The Equiphasic Approach

Determining the Axis

Predominantly
Positive

Predominantly
Negative

Equiphasic

The Quadrant Approach

1. Examine the QRS complex in leads I and aVF to determine
if they are predominantly positive or predominantly
negative. The combination should place the axis into one
of the 4 quadrants below.

Example 1

Negative in I, positive in aVF RAD

Example 2

Positive in I, negative in aVF

Predominantly positive in II

Normal Axis (non-pathologic LAD)

Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

Example 1

Equiphasic in aVF Predominantly positive in I QRS axis 0

Example 2

Equiphasic in II Predominantly negative in aVL QRS axis +150

Common causes of LAD

May be normal in the elderly and very
obese
Due to high diaphragm during pregnancy,
ascites, or ABD tumors
Inferior wall MI
Left Anterior Hemiblock
Left Bundle Branch Block
WPW Syndrome
Congenital Lesions
RV Pacer or RV ectopic rhythms
Emphysema

Common causes of RAD

Normal variant
Right Ventricular Hypertrophy
Anterior MI
Right Bundle Branch Block
Left Posterior Hemiblock
Left Ventricular ectopic rhythms or
pacing
WPW Syndrome

The Normal ECG

Normal Sinus Rhythm

Originates in the sinus node
Rate between 60 and 100 beats per min
P wave axis of +45 to +65 degrees, ie.
Tallest p waves in Lead II
Monomorphic P waves
Normal PR interval of 120 to 200 msec
Normal relationship between P and QRS
Some sinus arrhythmia is normal

Sinus Arrhythmia

ECG Characteristics:

Presence of sinus P waves

Variation of the PP interval which cannot be
attributed to either SA nodal block or PACs

When the variations in PP interval occur in phase with respiration, this is

considered to be a normal variant. When they are unrelated to respiration,
they may be caused by the same etiologies leading to sinus bradycardia.

Normal P wave
Atrial depolarisation
Duration 80 to 100 msec
Maximum amplitude 2.5 mm
Axis +45 to +65
Biphasic in lead V1
Terminal deflection should not exceed 1
mm in depth and 0.03 sec in duration

Normal P wave

PR interval
AV node conduction
From the beginning of P wave to the
beginning of q wave
120-200 ms

Normal QRS complex

Completely negative in lead aVR , maximum
positivity in lead II
rS in right oriented leads and qR in left oriented
leads (septal vector)
Transition zone commonly in V3-V4
RV5 > RV6 normally
Normal duration 50-110 msec, not more than
120 msec
Physiological q wave not > 0.03 sec

ECG showing qR pattern in lead III

,disappears on deep inspiration q wave
not significant
Mech:shift in the QRS axis

QRS-T angle
The normal t wave axis is similar to the
QRS axis
Normally the QRS-T angle does not
exceed 60 deg

Amplitude of QRS
Depends on the following factors
1.electrical force generated by the ventricular
myocardium
2.distance of the sensing electrode from the
ventricles
3.Body build;a thin individual has larger
complexes when compared to obese
individuals
4.direction of the frontal QRS axis

Normal T wave
Same direction as the preceding QRS
complex
Blunt apex with asymmetric limbs
Height < 5mm in limb leads and <10 mm
in precordial leads
Smooth contours
May be tall in athletes

ST segment
Merges smoothly with the proximal limb of
the T wave
No true horizontality

Normal u wave
Best seen in midprecordial leads
Height < 10% of preceding T wave
Isoelectric in lead aVL (useful to measure
QTc)
Rarely exceeds 1 mm in amplitude
May be tall in athletes (2mm)

QT interval
Normally corrected for heart rate
Bazetts formula
Normal 350 to 430 msec
With a normal heart rate (60 to 100), the
QT interval should not exceed half of the
R-R interval roughly

Measurement of QT interval
The beginning of the QRS complex is best
determined in a lead with an initial q wave
leads I,II, avL ,V5 or V6
QT interval shortens with tachycardia and
lengthens with bradycardia

Prolonged QTc
During sleep
Hypocalcemia
Ac myocarditis
AMI
Drugs like quinidine,procainamide,tricyclic
antidepressants
Hypothermia
HOCM

Advanced AV block or high degree AV

block
Jervell-Lange Neilson syndrome
Romano-ward syndrome

Shortened QT
Digitalis effect
Hypercalcemia
Hyperthermia
Vagal stimulation

Normal Variants in the ECG

Sinus arrhythmia
Persistent juvenile pattern
Early repolarisation syndrome
Non specific T wave changes

Persistent juvenile pattern

Features of ERPS
Vagotonia / athletes heart
Prominent J point
Concave upwards, minimally elevated ST segments
Tall symmetrical T waves
Prominent q waves in left leads
Tall R waves in left oriented leads
Prominent u waves
Rapid precordial transition
Sinus bradycardia

Early Recognition Prevents Streptokinase infusion !

Reporting an ECG

1. Patient Details
Whose ECG is it ?!

2. Standardisation and lead

placement
Is it properly taken ?

3. Analysis of Rate, Rhythm and

Axis

4. Segment and wave form

analysis

Final Impression
Does the ECG correlate with
the clinical scenario ?

Thank you !