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Intro to ECGs

Dr Evagoras Economides, MA (Cantab), BM BCh(Oxon), FACC

Recording - gram
Electrical activity - electro
Generated by the heart - cardio
Poles of a lead for viewing - electrode

Allows us to examine the flow of electricity

(depolarisation and repolarisation)
12 views allow us to move around
ECG - fundamental part of clinical medicine

Allows diagnosis of cardiac disorders

one of the most cost-effective investigations

2-D recording of 3-D process.

Cardiac impulse - transmission of
depolarisation wave through conducting

Cardiac conduction wave passes through

specialised pathway

Contraction of cardiac muscle results from

depolarisation of cells
Right bundle
ECG recorded on standard paper - rate 25 mm/s.
Large squares: 5mm = 0.2 sec.
Small squares: 1mm = 0.04 sec.
Standard ECG registers 12 leads (and rhythm strip
(II or V1)
ECG is surface registration of myocardial electrical
Wave travelling towards the lead
Positive deflection
Wave travelling away from the lead
Negative deflection
ECG machine is a potentiometer (volt meter)
Modern ECG - 12 leads
Limb leads look at heart in vertical plane
I, II, III, aVL, aVF, aVR.
Chest leads look at heart in horizontal plane
V1, 2, 3, 4, 5, 6.
Positions for leads I, II, III given by Einthovens

Records atrial depolarisation (following sinus
node discharge)
Wave travels inferiorly and from right to left.
Therefore normal P wave generates positive
deflection in lead II (negative in aVR!)
Each P wave should be conducted to ventricles
Rate of firing normally determines heart rate
P wave does not exceed 0.12 sec
Represents time taken under normal circumstances
for transmission of signal from atria to ventricles
through AV node and His-Purkinje system

Should be 0.12 to 0.20 sec duration

Prolonged in atrioventricular (heart) block when

there is an abnormality of the AV conduction

May be shortened in conditions where extra

conducting tissue exists
Electrical impulse:
AV node > bundle of His > bundle branches
Rapid conduction to ventricular myocardium
Represents ventricular depolarisation
If > 0.12 sec suggests defect in intraventricular
conduction (usually bundle branch block)
Direction of QRS determines = electrical axis.
Lies between QRS and T wave

Equates to plateau phase of repolarisation

Normally does not deviate above or below iso-

electric line by >1mm.

Deviation can indicate myocardial damage.

Elevation can imply infarction.
Depression can imply ischaemia.
Represents rapid phase of ventricular
Normally positive in leads I, II, (III), aVL,
aVF,V2-6 (i.e. QRS-T concordance).
Most sensitive area for looking at ventricular
disease processes
Length of interval varies with rate!

Prolongation can be:

Due to inherited conditions
Acquired e.g. due to drugs

When prolonged can cause of life-threatening

Axis: direction of the mean vector
of the wave of ventricular
depolarisation in the limb leads
(mean frontal QRS axis)
Lead I (+ve) is arbitrarily defined as 0 degrees
Normal axis between -30 and +90 degrees.
Beyond -30 = left axis deviation.
Beyond +90 = right axis deviation.
Can be calculated using leads I, II and III.
Can be variable

Usually assessed in lead II (because normal P

waves most obvious in this lead)

P (+) in I, II and aVF


P (-) in aVR


Each P followed by QRS

Look at P wave.
Look at PR interval:
If > 0.12-0.2 secs = AV block.
If< 0.12 secs = problem with conducting tissue.
Look at QRS complex:
Duration = 0.08-0.10 secs.
If longer ? Bundle branch blocks
? Presence of Q waves = infarct if present.
Look at ST segment
Should be iso-electric.
If elevated = myocardial infarct.
If depressed = myocardial ischaemia.
Look at T waves:
If inverted = ischaemia.
If peaked = hyperkalaemia (potassium).
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