KINE 439 - Dr.

Green Section 2 Electrophysiology and ECG Basics Rate & Axis

Introduction to Electrocardiography (ECG, EKG)

Electrocardiography - graphic recording of the electrical activity (potentials) produced by the conduction system and the myocardium of the heart during its depolarization / re-polarization cycle.

During the late 1800's and early 1900's, Dutch physiologist Willem Einthoven developed the early electrocardiogram. He won the Nobel prize for its invention in 1924. Hubert Mann first uses the electrocardiogram to describe electrocardiographic changes associated with a heart attack in 1920. The science of electrocardiography is not exact. The sensitivity and specificity of the tool in relation to various diagnoses are relatively low Electrocardiograms must be viewed in the context of demographics, health histories, and other clinical test correlates. They are especially

Cardiac Electrophysiology

Skeletal Muscle or Neuron Action Potential

Atrial Muscle (Nodal) Action Potential

Inward Na+ and Ca++ ions (depolarization) Outward K+ current (repolarization)

3 u Automaticity (u HR)

Threshold

Slow spontaneous Inward Na+ ions

d Automaticity (d HR)

Automaticity - a pacemaker cells ability to spontaneously depolarize, reach threshold, and propagate an AP

A
+
O

c t i o n
2 5

Myocardium Muscle Action Potential

o t e n t i a l
r r e s p o n d i n g

o f
E C

v e r s h o o t + 1 0 m v

2
5 0 5 0 0 A R P R R S P

- 2 - 5 - 7
R

0
A N

e s t i n g P o t e n t i a l - 9 0 m v

c t iv e T r a a + o u t

- 1

K N +a C a + +

Concept 1

Depolarization progressing from left to right

1.

Depolarization Sequence of a Strip of 5 Myocardial Cells

2.

3.

4.

D ( o r
W

e p o l a r i z a t i o n W a v e o f a S t r i p + + y o c a r d i a l M u s c l e C e l l s m i n u s
o f D e p o l a r i z a t io n o r P r o p i g a t io n o f A

o f t h
c

a v e

Concept 2

o C

R e p o l a r i z i n g D e p o l a r l a r i z eC d e l l D e p o l a r i z e d C e l l P e l l ( K + e f f l C xe l ) l ( N a + u i n
+ +

i z o Cf l

i n g l a r i z e ue x l l )

N K

a N
+

N aK
+

a K
+

N K

+ +

- - - + +

- - - -

- - - + +

T h e n e e d l e r e c o r d in g e i n s c r i b e s a n e g a c t oi v m e p l e b e c a u s e t h d e p o l a r i z t i o a w af r yo m it d e n t i r e t i m e d e p o a r iz in g

o f t To fh te h in s e e d l e T o h f e t h n i se e d l e e rl ee cc t o r or d d i en g l re e c c t ro o r dd ei n g e le c t r o d e in s c r i t i os b t ai p l lh y a s i c xb e c a u s e h a a l f t o o f pt a t o h l ls ey i t i v e b e c a u e t i m ae v t e h eo f w a c v oe m o pf l e x w o f nd e i s p om l ao r v i zi n a g t i t o h n e i ws a v e i s v u m r i no g t i ont hwg e a r d s d e p o l i at r i z t i o n t h e h i s l e t r it p h e i s o t mh e o r v t hoi n aw g l af r d s w t h e e n t i r o f t h e t i m e id t u i s r i n g t i m e t h e s t r i p i s m o v a i w ga y n d e p o l a r i z i n g

The Electrical System of the Heart

Inter- nodal Tracts SA Node AV Node

Left Bundle Branch

Anterior Superior Fascicle

Bundle of HIS

Posterior Inferior Fascicle Septal Depolarization Fibers

Purkinjie Fibers

Right Bundle Branch

Conduction System of the Heart: A Conceptual Model for Illustration

AV Node

Inter-nodal Tract

Left Bundle Branch

Bundle of HIS Septal Depolarization Fibers

SA Node

James Fibers

Anterior Superior Fascicle Posterior Inferior Fascicle

Right Bundle Branch

Bundle of Kent

Generation of the Electrocardiogram

Atrial Depolarization and the Inscription of the P-wave

SA node

AV node

Lead II electrode: 60 downward rotation from the horizontal 0 0

Delay (no electrical activity) before the beginning of ventricular depolarization due to AV node function

90

Ventricular Depolarization and the Inscription of the QRS complex

N o t e : t h e le f r i g h t v s m a l le li t t l e t o s v f e r oc t mo r c o t v e n r a t h to h f m

1 .

T s he e t u m p in s i d e d e p o la a w a y f r e c o r d

o u t a n r i z a t io r o m t h i n g L e

d e d n e a d

p o l a r iz t h e r e s w a v e m e l e c t r o I I

e u l t i n g o 6 o0 v e sL o e a d I I e l e c 6 0 d o w n w d e

p a e n t r ic t r ic l e n d c e o v ed e p o

r o t a t i o n a on g f r o m t h e h o

2 .

T h e r le e s f tt v ef nt h t re i c l e o d e p o la r i z e s c o u n t e f r o m t h e i n s id e o u t mh a i n t e c a r d i a c v e c t o w h i c h i s e s s e n t i a ll y s u m o f a l l o f t h e s m v e c t o r s ( i n c lu d in g t c o n t r i b u r t i o nh t f rv o e m n t rt hi g I n a n o r m a l h e a r t , t is a l w a y s m o v i n g d t o w a r d L e a d I I , g e n m o s t l y p o s i t i v e Q R

r - c lo a n d r , t h e a l l d h e s ce l e h is v i r e c t e r a t S c o

c k w i s e c r e a t e s ( l a r g e a r r o w a l g e b r a i c e p o la r i z a t io n m a l l e c t o r l y in g a m p l e x

Ventricular Repolarization and the Inscription of the T-wave

The ECG Complex with Interval and Segment Measurements

ECG Paper and related Heart Rate & Voltage Computations

Memorize These 2

The Concept of a Lead

Lead II
Right arm (RA) negative, left leg (LL) positive, right leg (RL) is always the ground. This arrangement of electrodes enables a "directional view" recording of the heart's electrical potentials as they are sequentially activated throughout the entire cardiac cycle

+
Electrocardiograph

The Concept of a Lead

Lead II
The directional flow of electricity from Lead II can be viewed as flowing from the RA toward the LL and passing through the heart (RA is negative LL is positive. Also, it is useful to imagine a camera lens taking an "electrical picture" of the heart with the lead as its line of sight

The Concept of a Lead

Leads I, II, and III

By changing the RA arrangement of which arms or legs are positive or negative, two other leads ( I & III ) can be RA created and we have two more "pictures" of the heart's electrical activity from different angles. LEAD III Lead I: RA is neg. and LL LA is pos. Lead III: LA is neg. and LL is pos.

LA

+ LA
LEAD I

+LL
LEAD II

Remember, the RL is always the ground and never takes on a positive or negative charge.

The Concept of a Lead

Augmented Voltage Leads AVR, AVL, and AVF LEAD AVR RA RA & LA

LEAD AVL

By combining certain limb leads into a central terminal, which serves as the negative electrode, other leads could be formed to "fill in the gaps" in terms of the angles of directional recording. These leads required augmentation of voltage to be read and are thus labeled.

LA

- RL RA &
LL

LL & LA

LEAD AVF

The Concept of a Lead

Summary of the Limb Leads

LEAD AVR

LEAD AVL

-150o

-30o 0o
LEAD I

Each of the limb leads (I, II, III, AVR, AVL, AVF) can be assigned an angle of clockwise or counterclockwise rotation to describe its position in the frontal plane. Downward rotation from 0 is positive and upward rotation from 0 is negative.

60o 120o
LEAD III

90

LEAD II

LEAD AVF

The Concept of a Lead

The Precordial Leads

4th intercostal V1 V2 Each of the 6 V3 precordial leads is space V4 V5 V6 unipolar (1 electrode constitutes a lead) and is designed to view the electrical activity of the heart in the horizontal or V1 - 4th intercostal space - right margin of sternum V2 - 4th intercostal space - left margin of sternum transverse plane V3 - linear midpoint between V2 and V4 V4 - 5th intercostal space at the mid clavicular line V5 - horizontally adjacent to V4 at anterior axillary line V6 - horizontally adjacent to V5 at mid-axillary line

Hexaxial Array for Axis Determination determination of the angle of the HEART AXIS in the frontal plain

Hexaxial Array for Axis Determination Example 1

Lead I

If lead I is mostly positive, the axis must lie in the right half of of the coordinate system (the main vector is moving mostly toward the leads positive electrode)

Hexaxial Array for Axis Determination Example 1

Lead AVF

If lead AVF is mostly positive, the axis must lie in the bottom half of of the coordinate system (again, the main vector is moving mostly toward the leads positive electrode

Hexaxial Array for Axis Determination Example 1

I AVF

Combining the two plots, we see that the axis must lie in the bottom right hand quadrant

Hexaxial Array for Axis Determination Example 1

I AVF AVL

Once the quadrant has been determined, find the most equiphasic or smallest limb lead. The axis will lie about 90o away from this lead. Given that AVL is the most equiphasic lead, the axis here is at approximately 60o.

Hexaxial Array for Axis Determination Example 1

I AVF AVL

Since QRS complex in AVL is a slightly more positive, the true axis will lie a little closer to AVL (the depolarization vector is moving a little more towards AVL than away from it). A better estimate would be about 50o (normal axis).

Hexaxial Array for Axis Determination Example 2

Lead I

If lead I is mostly negative, the axis must lie in the left half of of the coordinate system.

Hexaxial Array for Axis Determination Example 2

Lead AVF

If lead AVF is mostly positive, the axis must lie in the bottom half of of the coordinate system

Hexaxial Array for Axis Determination Example 2

I AVF

Combining the two plots, we see that the axis must lie in the bottom left hand quadrant (Right Axis Deviation)

Hexaxial Array for Axis Determination Example 2

I AVF II

Once the quadrant has been determined, find the most equiphasic or smallest limb lead. The axis will lie about 90o away from this lead. Given that II is the most equiphasic lead, the axis here is at approximately 150o.

Hexaxial Array for Axis Determination Example 2

I AVF II

Since the QRS in II is a slightly more negative, the true axis will lie a little farther away from lead II than just 90o (the depolarization vector is moving a little more away from lead II than toward it). A better estimate would be 160o.

Precise Axis Calculation

Precise calculation of the axis can be done using the coordinate system to plot net voltages of perpendicular leads, drawing a resultant rectangle, then connecting the origin of the coordinate system with the opposite corner of the rectangle. A protractor can then be used to measure the deflection from 0.

Net voltage = 12

Since Lead III is the most equiphasic lead and it is slightly more positive than negative, this axis could be estimated at about 40o.

Net voltage = 7