ELECTROCARDIOGRAM (ECG

Introduction Of Basic Principl

Dian Puspita Sari

Objectives

At the end of this session, students

expected to be able to:

Explain definition of ECG and the use of ECG

Explain about electrodes and leads
Explain about procedure of ECG
Explain about Unipolar and Bipolar Leads
Explain about principles of ECG waves and
normal pattern of ECG
Mention how to asses Heart rhythm, heart
rate, axis, and several important abnormalities

Introduction

ECG records potential differences caused

by cardiac excitation
Give information about:

Heart position, Relative chamber size, Heart

rhythm, Impulse origin/propagation,
Rhythm/conduction disturbances, Extent and
location of cardiac inschaemia/infarct, Changes
in electrolyte concentration

Typical ECG report shows cardiac cycles

from 12 vantage points by using 10
electrodes

Terms

Electrode : electrical recording device,

placed in patients body

Limbs electrodes : Right Arm (RA), Left Arm

(LA), Left Leg(LL), Right Leg (ground)
Precordial electrodes : V1, V2,, V6

Lead : electrical picture of the heart;

picture in each lead can be different
depend on the direction of electrical
impulse.

Electrodes

Limbs Electrode

Precordial
Electrode

Location for Precordial

Electrode

V1 : right 4th intercostal space,

parasternal line
V2: left 4th intercostal space, parasternal
line
V3 : between V2 and V4
V4 : left 5th intercostal space,
midclavicular line
V5 : horizontal to V4, anterior axillary
line
V6: horizontal to V5, mid axillary line

ECG Leads

2 Basic types:

Unipolar leads : lead aVR, aVL, aVF, V1 V6

point where electrode is placed is the (+)
pole, and negative pole is combination of
other electrodes

Bipolar leads : lead I, II, III lead between

2 electrodes, where one electrodes serve as
(-) pole and other as (+) pole

Unipolar Leads

Perpendicular
Plane

Frontal Plane

Bipolar Leads
Bipolar
Leads

(-)
electro
des

(+)
electro
des

RA

LA

II

RA

LL

III

LA

LL

Axial Reference System

Principles of ECG Waves

An electrical force directed toward the (+) pole of a lead

results in an upward deflection on ECG recording of that
lead
Forces that head away form the (+) electrode result in a
downward deflection
Magnitude of deflection, either upward or downward,
reflects how parallel the electrical force is to the axis of
lead being examined. The more parallel the electrical
force to the lead, the greater the magnitude of the
deflection
An electrical force directed perpendicular to an ECG lead
does not register any activity by that lead (a flat line on
recording)

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)

LL

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)
II = RA vs. LL (+)

LL

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)
II = RA vs. LL (+)

III = LA vs. LL (+)

LL

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)
II = RA vs. LL (+)

III = LA vs. LL (+)

Augmented Limb Leads:

VR = (LA-LL) vs. RA(+)

LL

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)
II = RA vs. LL (+)

III = LA vs. LL (+)

Augmented Limb Leads:

VR = (LA-LL) vs. RA(+)

VL = (RA-LL) vs. LA(+)

LL

G Recordings (QRS Vector pointing leftward, inferiorl

& posteriorly)
Bipolar Limb Leads:
RA
LA
I = RA vs. LA (+)
II = RA vs. LL (+)

III = LA vs. LL (+)

Augmented Limb Leads:

VR = (LA-LL) vs. RA(+)

VL = (RA-LL) vs. LA(+)

VF = (RA-LA) vs. LL(+)

LL

6 Precordial (Chest) Leads

Spine

V6
V5

Sternum
V1

V2

V3

V4

ECG Waves

Pay more
attention to
various shape of
normal QRS
complex

Normal ECG

Setting

Voltage calibration determine the

height of waves. Normally, 1mV= 10
mm (2 large boxes)

Speed : normally 25 mm/sec each

1mm = 0.04 sec

ECG Interpretation

Setting
Heart Rhythm
Heart Rate
Intervals
Axis (mean QRS axis)
Abnormalities of P wave
Abnormalities of QRS
Abnormalities of ST and T wave

Heart Rate
HR =

(25 mm/sec x 60
sec/min)

Number of mm between
beats
HR =

OR

1500

Number of mm between beats

OR
HR =

300
Number of large boxes

Heart Rate

Heart Rhythm

Sinus Rhythm:

Every P wave is followed by a QRS complex

Every QRS is preceed by a P wave
P wave is upright in leads I, II, III
PR interval is greater 0.12 sec (3 small boxes)

Normal Sinus Rhythm

Sinus rhythm with HR between 60-100 x/min

If < 60 x/min Sinus Bradycardia
If> 100x/min Sinus Tachycardia

Sinus Tachycardia

Sinus Bradycardia

Sinus Arhytmia

Intervals

PR, QRS and QT intervals

Check the limb leads to asses intervals

Lead I, II, III, aVR, aVL, aVF

Take measurement in a lead where the interval is
longest in duration

PR interval : from beginning of P wave until

onset of QRS
QRS interval: from beginning to the end of QRS
complex
QT interval : from beginning of QRS to the end
of T wave. Corrected QT QT/R-R

Intervals
Inter
val

QRS
PR
QT

Norma
l
Durati
on
0.12 s
0.120.2 s
0.4

Analog

3 small boxes
3-5 small boxes
10 small boxes or 2 large
boxes

Mean QRS Axis (Axis)

Normal Axis : -30o until +90o

Mean QRS Axis (Axis)

Left Axis
Deviation

Normal
Axis
Right Axis
Deviation

Mean QRS Axis (Axis)

Look at Lead I and II; if QRS primarily upward in both
lead, then the axis is normal.
If not:
Determine the mean axis

Inspect the six limb leads and determine which one contain
QRS that is most isoelectric. The mean axis is perpendicular
to that.

Determine the direction

Inspect the lead that is perpendicular to lead that contain

the isoelectric QRS complex. If QRS in that perpendicular
lead is primarily upward,then the mean axis points to the
(+) pole of that lead. If primarily negative, than the mean
axis points to (-) pole of that lead

Axis Deviation

Axis Deviation

P Wave Abnormalities

P wave represents atrial depolarization

(first is right atrium, quickly followed by
left atrium)
Best visualized in Lead II
Abnormalities of P wave abnormalities
of Atrium

Tall P wave in lead II (>2.5mm in height)

right atrial enlargement
Negative deflection > 1mm wide and > 1mm
deep in lead V1 left atrial enlargement

Right Atrial Enlargement

Left Atrial Enlargement

QRS complex

QRS complex represents ventricular

depolarization
Normal QRS complex:

Small Q waves are permissible in Lead I, aVL, and

V6
RSR pattern in V1 is normal if less than 0.12 s
Look at abN pattern to compare!

Abnormalities of QRS complex can describe:

Ventricular hypertrophy
Bundle Branch Block
Myocardial infarction

Abnormalities of QRS complex :

Ventricular Hypertrophy

Right Ventricular Hypertrophy

R > S in V1
Right axis deviation

Left Ventricular Hypertrophy

(S in V1) + (R in V5 or V6) 35 mm,

OR
R in aVL > 11 mm, OR
R in lead I > 15 mm

LVH

RVH

Abnormalities of QRS complex :

Myocardial Infarct

Normal Q wave :

Short duration ~ 1 small box, and Low

magnitude (< 25%of the QRS total height)

Pathologic Q wave :

Duration > 1 small box, and height > 25%

QRS total height
Represents transmural MI
Permanent evidence of infarct
Location of MI can be determined

Abnormalities of ST
segment

Normal ST segment : should be

isoelectric
Example of Abnormalities ST segment :

ST elevation infarct
ST depresion ischaemia

ST elevation in Anterior
Infarct

Picture of ST elevation
Picture of ST depression

T wave

Normal T wave maybe inverted in :

Lead III
Lead aVR
Lead V1

Abnormal T wave maybe seen in :

Myocardial Infarct (depressed/inverted T

wave)
Ventricular Arrhytmia
etc

Thank you
ECG records were taken from
www.learntheheart.com