• S-A node - normal rhythmical impulse generator

• Internodal pathways - that conduct the impulse from

SA node to A-V node
• A-V node- impulse from atria is delayed before
passing into ventricles
• A-V bundle- Conducts the impulse from atria into
ventricles (left & right bundle branches of Purkinje
fibers) which conduct the impulse throughout the
ventricles.
Uses of ECG
• Electrocardiogram is useful in determining & diagnosing the
following
1. Heart rate
2. Heart rhythm
3. Abnormal electrical conduction
4. Poor blood flow to heart muscle (Ischemia)
5. Heart attack
6. Coronary artery disease
7. Hypertrophy of heart chambers
ECG Leads & Lead systems
• ECG is recorded by using different lead systems
• Electrodes & wire through which the body parts are
connected to ECG machine are called ECG leads
Different lead systems used for ECG recording are
1. Bipolar limb lead / Standard limb lead system
2. Unipolar limb lead system
• a) Augmented unipolar limb lead system
• b) Unipolar chest lead system
 PROCEDURE

• Proper patient positioning and restraint is a must.

- Right lateral recumbancy non-conductive surface. if not
possible Other positions are acceptable (including
standing).
- Head flat, in line with body
- Legs perpendicular to body, parallel to one another
- Patient must be still: no panting or purring, no moving
- Minimize contact with patient: no petting
Try these techniques to minimize panting, shaking or
purring:
• For deep-chested animals, such as Doberman
pinschers, place your hands on either side of the
chest and apply moderate pressure.

• To reduce panting, hold the patient’s mouth

closed. Be careful not to obstruct breathing.

• To stop purring, wave an alcohol-soaked cotton

ball under the patient’s nose.
• Connect all the electrodes as per the marking
given in the electrode securely by strapping it.
RA: Right Arm. ( RED )
LA: Left Arm. ( YELLOW )
LL: Left Leg. ( GREEN )
RL: Right Leg (Ground). ( BLACK )

• Before keeping the electrode on the point,

apply electrolyte jelly (to reduce skin
resistance). and attach the electrode clips to
the skin.
8-Step Method ECG Interpretation
1. Rate
2. Rhythm
3. Axis
4. P wave
5. PR interval
6. QRS complex
7. QT interval
8. ST segment and T wave
„‘P’ WAVE:
• A positive wave & first wave in ECG. It is also called atrial complex
• Cause: sequential depolarization of right & left atrial musculature
Depolarization spreads from SA node to all parts of right & left atrial
musculature
• Duration: Normal duration of ‘P’ wave is 0.1 second
• Amplitude: Normal amplitude of ‘P’ wave is 0.1 to 0.12 mV
• Morphology: ‘P’ wave is normally positive (upright) in leads I, II, aVF,
V4, V5 & V6. It is normally negative (inverted) in aVR. It is variable in
the remaining leads, i.e. it may be positive, negative, biphasic or flat
Clinical Significance
• Variation in the duration, amplitude & morphology of ‘P’ wave helps in
diagnosis of several cardiac problems such as:
1. Right atrial hypertrophy: ‘P’ wave is tall (more than 2.5 mm) in lead II.
It is usually pointed
2. Left atrial dilatation or hypertrophy: It is tall & broad based or M
shaped
3. Atrial extrasystole: Small & shapeless ‘P’ wave, followed by a small
compensatory pause
4. Hyperkalemia: ‘P’ wave is absent or small
5. Atrial fibrillation: ‘P’ wave is absent
6. Middle AV nodal rhythm: ‘P’ wave is absent
7. Sinoatrial block: ‘P’ wave is inverted or absent
8. Atrial paroxysmal tachycardia: ‘P’ wave is inverted
‘QRS’ Complex
• ‘QRS’ complex is also called the initial ventricular complex. ‘Q’
wave is a small negative wave. It is continued as tall ‘R’ wave,
which is a positive wave. ‘R’ wave is followed by a small negative
wave, the ‘S’ wave.
Cause: ‘QRS’ complex is due to depolarization of right & left
ventricular musculature.
• ‘Q’ wave ---- depolarization of basal portion of interventricular
septum.
• ‘R’ wave ----- depolarization of apical portion of interventricular
septum & apical portion of ventricular muscle.
• ‘S’ wave ------ depolarization of basal portion of ventricular muscle
near the atrioventricular ring.
Clinical Significance
• Variation in duration, amplitude & morphology of
‘QRS’ complex helps in diagnosis of several
cardiac problems such as:
1. Bundle branch block: QRS is prolonged or
deformed
2. Hyperkalemia: QRS is prolonged.
 ‘T’ Wave
Final ventricular complex & is a positive wave.
Cause: Repolarization of ventricular musculature.
Duration: Normal duration of ‘T’ wave is 0.2 second.
Amplitude: Normal amplitude of ‘T’ wave is 0.3 mV.
Morphology:
1. ‘T’ wave is normally positive in leads I, II and V5 & V6
2. It is normally inverted in lead aVR
3. It is variable in the other leads, i.e. it is positive, negative or flat
Clinical Significance
• Variation in duration, amplitude & morphology of ‘T’ wave helps in
diagnosis of several cardiac problems such as:
1. Acute myocardial ischemia: Hyperacute ‘T’ wave develops.
Hyperacute ‘T’ wave refers to a tall & broad-based ‘T’ wave, with
slight asymmetry.
2. Old age, hyperventilation, anxiety, myocardial infarction, left
ventricular hypertrophy & pericarditis: ‘T’ wave is small, flat or
inverted
3. Hypokalemia: ‘T’ wave is small, flat or inverted
4. Hyperkalemia: ‘T’ wave is tall
Prolonged P-R interval in first degree heart
block
‘Q-T’ Interval
‘Q-T’ interval
• Interval between the onset of ‘Q’ wave & end of ‘T’ wave
• Indicates the ventricular depolarization & ventricular repolarization
Duration
• Normal duration of Q-T interval is between 0.4 & 0.42 sec.
Clinical Significance
1. ‘Q-T’ interval is prolonged in long ‘Q-T’ syndrome, myocardial
infarction, myocarditis, hypocalcemia & hypothyroidism
2. ‘Q-T’ interval is shortened in short ‘Q-T’ syndrome & hypercalcemia
‘S-T’ Segment
‘S-T’ segment: Time interval between the end of ‘S’ wave & onset of ‘T’ wave.
It is an isoelectric period.
J Point: Point where ‘S-T’ segment starts is called ‘J’ point. It is the junction between the
QRS complex & ‘S-T’ segment.
Duration of ‘S-T’ Segment: Normal duration of ‘S-T’ segment is 0.08 to 0.12 second.
Clinical Significance
Variation in duration of ‘S-T’ segment & its deviation from isoelectric base indicates
following pathological conditions:
1. Elevation of ‘S-T’ segment occurs in anterior myocardial infarction, left bundle branch
block & acute pericarditis. In athletes, ‘S-T’ segment is usually elevated
2. Depression of ‘S-T’ segment occurs in acute myocardial ischemia, posterior myocardial
infarction, ventricular hypertrophy & hypokalemia
3. ‘S-T’ segment is prolonged in hypocalcemia
4. ‘S-T’ segment is shortened in hypercalcemia
‘R-R’ Interval
‘R-R’ interval: Time interval between two consecutive ‘R’ waves
Significance: ‘R-R’ interval signifies duration of one cardiac cycle
Duration: Normal duration of ‘R-R’ interval is 0.8 second
Significance of Measuring ‘R-R’ Interval: helps to calculate:
1. Heart rate
2. Heart rate variability
1. Heart Rate
• Heart rate is calculated by measuring the number of ‘R’ waves per unit
time Calculation of heart rate Time is plotted horizontally (X-axis)
• On X-axis, interval between two thick lines is 0.2 sec (0.04x 5 = 0.2 sec)
• Time duration for 30 thick lines is 6 seconds. Number of ‘R’ waves (QRS
complexes) in 6 seconds (30 thick lines) is counted & multiplied by 10
to obtain heart rate.
 Cardiac Axis

• Principle # 1 : When a positive sensing electrode

sees an electrical impulse as coming head on, it will
write the highest amplitude deflection on the EKG
paper.
• Principle # 2 : When the positive sensing electrode
sees an electrical impulse crossing it on a
perpendicular path, it will write the smallest
amplitude deflection on the EKG paper.
 Rhythm
• 4 Questions
• 1. Are normal P waves present?
• 2. Are QRS complexes narrow or wide (≤ or ≥ 0.12)?
• 3. What is relationship between P waves and QRS complexes?
• 4. Is rhythm regular or irregular?
• Sinus rhythm = normal P waves, narrow QRS complexes, 1 P wave to
every 1 QRS complex, and regular rhythm
Classification
• In arrhythmia, SA node may / may not be pacemaker
• If SA node is not the pacemaker, any other part of heart such as atrial
muscle, AV node & ventricular muscle becomes the pacemaker
• Accordingly, arrhythmia is classified into two types:
A. Normotopic arrhythmia
B. Ectopic arrhythmia
Normotopic arrhythmia: Irregular heartbeat, in which SA node is
pacemaker
• Normotopic arrhythmias - three types:
1. Sinus arrhythmia
2. Sinus tachycardia
3. Sinus bradycardia
 Sinus Arrhythmia
• Sinus arrhythmia is a normal rhythmical increase & decrease in
heart rate, in relation to respiration
• It is also called Respiratory Sinus Arrhythmia (RSA)
• Normal sinus rhythm means -- normal heartbeat with SA node as
pacemaker – i.e., is about 72 per minute
• However, in a normal healthy person, heart rate varies according
to phases of respiratory cycle
• Heart rate increases during inspiration & decreases during
expiration
ECG Changes
• ECG is normal during sinus arrhythmia. Only the duration of R-R
interval varies rhythmically according to phases of respiration (Fig.
96.1). It is shortened during inspiration & prolonged during
expiration
Sinus Tachycardia
• In tachycardia, heart rate usually increase higher than 100 beats
per minute.
ECG Changes: ECG is normal in sinus tachycardia, except for short
R-R intervals because of increased heart rate that is about 150 per
minute instead of the normal 72 per minute (determined from the
time intervals between QRS complexes).
• R-R interval decreases to 0.4 sec rather 0.8 seconds
General causes
1. Increased body temperature: Leading to increase in SA node
discharge
• Heart rate increases about 10 beats per minute / each degree
Fahrenheit (18 beats / ºC) increase in body temperature, up to a
body temperature of about 105°F (40.5°C)
• Beyond this, heart rate may decrease because of progressive
Conditions that results in - Sinus Tachycardia
• Occurs during physiological & pathological conditions
Physiological conditions
1. Exercise 2. Emotion 3. High altitude 4. Pregnancy
Pathological conditions
1. Fever 2. Anemia
3. Hyperthyroidism 4. Hemorrhagic shock
5. Cardiomyopathy 6. Valvular heart disease
7. Hypersecretion of catecholamines
Sinus Bradycardia
• Reduction in SA node impulses --- Resulting in decreased heart
rate.
• Heart rate is less than 60/minute.
• ECG Changes: ECG shows prolonged waves and prolonged R-R
interval
• It occurs during sleep
• Very common in athletes due to cardiovascular reflexes, in
response to increased force of contraction of heart.
• Bradycardia in Athletes: Athlete’s heart is larger & considerably
stronger than that of a normal person.
• Stroke volume & cardiac output is more even during periods of
rest.
• When athlete is at rest, excessive quantities of blood pumped into
Causes of Sinus Bradycardia
Physiological conditions: 1. Sleep 2. Athletic heart
Pathological conditions:
1. Heart attack 2. Hypothermia
3. Hypothyroidism 4. Disease of SA node
5. Congenital heart disease 6. Degenerative process of aging
7. Increased intracranial pressure
8. Use of certain drugs like beta blockers, channel blockers, digitalis
& other antiarrhythmic drugs
9. Atherosclerosis: Bradycardia due to atherosclerosis of carotid
artery, at the region of carotid sinus is called carotid sinus
syndrome (CSS)
Ectopic Arrhythmia
• Ectopic arrhythmia is abnormal heartbeat, in which one of the structures of
heart other than SA node becomes pacemaker.
• Ectopic arrhythmia is further divided into:
1. Homotopic arrhythmia, in which the impulses for heartbeat arise from any
part of conductive system
2. Heterotopic arrhythmia, in which the impulses arise from the musculature of
heart other than conductive system
Different Ectopic Arrhythmia
1. Heart block
2. Extrasystole
3. Paroxysmal tachycardia
4. Atrial flutter
5. Atrial fibrillation
6. Ventricular fibrillation
Heart Block
• Blockage in transmission of impulses generated by
SA node of conductive system.
• Impulses fail to reach cardiac musculature, resulting
in ectopic arrhythmia.
• Based on area affected, heart block is classified into
two types
1. SA block
2. AV block
AV Block
Heart block in which impulses fail to reach ventricles from atria (from AV
node) because of defective conductive system.
Two types of AV block :
1. Incomplete heart block
2. Complete heart block
Incomplete Heart Block: Condition in which impulse transmission from
atria to ventricles is slow but not blocked completely. Impulses reach
ventricles late.
Incomplete heart block is of four types:
i. First degree heart block
ii. Second degree heart block
iii. Third degree heart block
iv. Bundle branch block
i. First Degree Block.
• Heart block in which conduction of impulses through AV node is
very slow, i.e. AV nodal delay is longer.
• It is also called delayed conduction as there is a delay in conduction
but not actual blockage of conduction
• In ECG, P-R interval is very much prolonged and is more than 0.2
second.
• It is also caused by rheumatic fever & some drugs. It does not
produce any symptom.
ii. Second Degree Block
• Heart block in which some of the impulses produced by SA node
fail to reach ventricles.

• In this instance, there will be an atrial P wave but no QRS-T wave,

and it is said that there are “dropped beats” of ventricles.

• It is also called the partial heart block. When some of the impulses
from SA node fail to reach the ventricles, one ventricular
contraction occurs for every 2, 3 or 4 atrial contractions, i.e. 2 : 1, 3
: 1 or 4: 1.

• In ECG, the ventricular complex (QRST) is missing accordingly

Third-Degree (Complete) AV Block

1.P waves are present, with a regular atrial rate

faster than the ventricular rate
2.QRS complexes are present, with a slow (usually
fixed) ventricular rate
3.The P wave bears no relation to the QRS
complexes, and the PR intervals are completely
variable
Third-Degree (Complete) AV Block
Bundle Branch Block
• Due to dysfunction of right or left branch of bundle of His.
• During this, the impulse from atria reaches unaffected ventricle first
• Then, from here, the impulse is conducted first through the healthy
branch & then into the damaged side
• Distribution of impulse takes more time than usual, so QRS-
complex is wider than normal (more than 0.12 s)
• So, ECG shows normal ventricular wave, but the QRS complex is
prolonged or deformed.
• In right bundle branch block -- Late activation of right ventricle -
which is shown by a tall double R-wave & a deep wide S-wave
• In left bundle branch block --- Late activation of left ventricle from
apex towards basis.
 Complete Heart Block
• Also called as complete AV block or third degree heart block
• When the condition causing poor conduction in A-V node or A-V bundle becomes severe,
impulses of SA node fail to reach ventricles.
• In this instance, ventricles spontaneously establish their own signal, usually originating in A-V
node or A-V bundle.
• Because of this, ventricles beat in their own rhythm, independent of atrial beat.
• It is called idioventricular rhythm.
• Therefore, the P waves become dissociated from the QRS-T complexes
• Furthermore, there is no relation between the rhythm of P waves & that of QRS-T complexes
because the ventricles have “escaped” from control by atria & they are beating at their own
natural rate, controlled most often by rhythmical signals generated in the A-V node or A-V
bundle.
Causes: i. Disease of AV node, which leads to AV nodal block
ii. Defective conductive system below level of AV node, causing infranodal block.
Atrial Flutter
• An arrhythmia characterized by rapid ineffective atrial contractions,
caused by ectopic foci originating from atrial musculature.
• Both the atria beat rapidly like the wings of a bird, hence the name
atrial flutter.
• Atrial rate is about 250 to 350/minute.
• Maximum number of impulses conducted by AV node is about 230
to 240 /minute. So, during atrial flutter, the second degree of heart
block occurs.
• Ratio between atrial beats & ventricular beats is 2 : 1 or 3 : 1
• Prolonged atrial flutter may lead to atrial fibrillation or heart failure.
 Atrial Fibrillation

• Arrhythmia characterized by rapid & irregular atrial contractions at

the rate of 300 to 400 beats/minute.
• Mostly due to circus movement of impulses within atrial
musculature.
• P wave is absent in ECG.
• Though it is not life threatening, it may cause complications.
• If it continues for long time, it may cause blood clot and blockage
of blood flow to vital organs.
Ventricular Fibrillation
• Dangerous cardiac arrhythmia,

• characterized by rapid & irregular twitching of ventricles.

• Ventricles beat very rapidly & irregularly due to movement of impulses

within ventricular muscle.

• Heart rate reaches 400 to 500/minute.

• This type of arrhythmia is serious as it leads to death, since the ventricles

cannot pump blood.

• Very common during electric shock & ischemia of conductive system.

Abnormal ECG Deflection Wave Patterns

Sinus Bradycardia

Rate = 40-59 b.p.m.

Sinus Tachycardia

Rate = 101-160 b.p.m.

Causes
•CHF, hypoxia, pulmonary edema
•Increased temperature
•Stress or response to pain
Sinus Arrhythmia

Rate = 45-100 b.p.m.

Sinus Arrest

Causes
Myocarditis
MI
Digitalis toxicity
Atrial Flutter

Rate = 250-350 b.p.m.

Precipitates CHF
Atrial Fibrillation (afib)

Causes
COPD
CHF
AV block

Causes
•Digitalis toxicity
•Acute infection
•MI
•Degeneration of the conductive tissue.
 Ventricular Tachycardia
(V-tac)

Rate = 100-220 b.p.m.

Causes
•CAD
•Acute MI
•Digitalis toxicity
•CHF
Ventricular Fibrillation (V-fib)

Causes
Acute MI
Asystole