Chapter 3

Conquering the ECG

Besides the stethoscope, the electrocardiogram (ECG) is the oldest and most
enduring tool of the cardiologist. A basic knowledge of the ECG will enhance the
understanding of cardiology (not to mention this book).

Electrocardiography
At every beat, the heart is depolarized to trigger its contraction. This electrical
activity is transmitted throughout the body and can be picked up on the skin.
This is the principle behind the ECG. An ECG machine records this activity
via electrodes on the skin and displays it graphically. An ECG involves attaching
10 electrical cables to the body: one to each limb and six across the chest.

ECG terminology has two meanings for the word “lead”:

• the cable used to connect an electrode to the ECG recorder

• the electrical view of the heart obtained from any one
combination of electrodes

Carrying out an ECG

1) Ask the patient to undress down to the waist and lie down
2) Remove excess hair where necessary
3) Attach limb leads (anywhere on the limb)
4) Attach the chest leads (see Figure 1) as follows:

• V1 and V2: either side of the sternum on the fourth rib (count down from the
sternal angle, the second rib insertion)
• V4: on the apex of the heart (feel for it)
• V3: halfway between V2 and V4
• V5 and V6: horizontally laterally from V4 (not up towards the axilla)

5) Ask the patient to relax

6) Press record

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Chapter 3

2
Angle of
Louis 3

V2 6
V1 V6
V3 V5
V4

Figure 1. Standard attachment sites for chest leads.

The standard ECG uses 10 cables to obtain 12 electrical views of the heart.
The different views reflect the angles at which electrodes “look” at the heart and
the direction of the heart’s electrical depolarization.

Limb leads
Three bipolar leads and three unipolar leads are obtained from three electrodes
attached to the left arm, the right arm, and the left leg, respectively. (An electrode
is also attached to the right leg, but this is an earth electrode.) The bipolar limb
leads reflect the potential difference between two of the three limb electrodes:

• lead I: right arm–left arm

• lead II: right arm–left leg
• lead III: left leg–left arm

The unipolar leads reflect the potential difference between one of the three limb
electrodes and an estimate of zero potential – derived from the remaining two limb
electrodes. These leads are known as augmented leads. The augmented leads and
their respective limb electrodes are:

• aVR lead: right arm

• aVL lead: left arm
• aVF lead: left leg

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 Conquering the ECG

aVR (-150˚)
aVL (-30˚) WE

I (0˚)
I 0

III (+120˚)
II (+60˚)
Ii aro
aVF (+90˚)

Figure 2. The limb leads looking at the heart in a vertical plane.

View Lead

Inferior II, III, aVF

Anterior I, aVL, V1–V3
Septal V3, V4
Lateral V4–V6

Table 1. ECG leads and their respective views of the heart.

Chest leads
Another six electrodes, placed in standard positions on the chest wall, give rise to
a further six unipolar leads – the chest leads (also known as precordial leads),
V1–V6. The potential difference of a chest lead is recorded between the relevant
chest electrode and an estimate of zero potential – derived from the average
potential recorded from the three limb leads.

Planes of view
The limb leads look at the heart in a vertical plane (see Figure 2), whereas the chest
leads look at the heart in a horizontal plane. In this way, a three-dimensional
electrical picture of the heart is built up (see Table 1).

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Chapter 3

PERFORMING DOGS
British physiologist Augustus D Waller of St Mary’s Medical School, London,
published the first human electrocardiogram in the British Medical Journal in
1888. It was recorded from Thomas Goswell, a technician in the laboratory,
using a capillary electrometer. After that, Waller used a more available subject
for his demonstrations – his dog Jimmy, who would patiently stand with his
paws in glass jars of saline.

AVN

Bundle of His
SAN

Anterior fascicle

Left bundle branch

Right bundle branch

Internodal
pathways Purkinje fibers

Posterior fascicle

Figure 3. The cardiac depolarization route. AVN: atrioventricular node; SAN: sinoatrial
node. Reproduced with permission from WB Saunders (Guyton A, Hall J. Textbook of
Medical Physiology. Philadelphia: WB Saunders, 1996).

Depolarization of the heart

The route that the depolarization wave takes across the heart is outlined in
Figure 3. The sinoatrial node (SAN) is the heart’s pacemaker. From the SAN, the
wave of depolarization spreads across the atria to the atrioventricular node (AVN).
The impulse is delayed briefly at the AVN and atrial contraction is completed.

The wave of depolarization then proceeds rapidly to the bundle of His where it
splits into two pathways and travels along the right and left bundle branches. The
impulse travels the length of the bundles along the interventricular septum to the
base of the heart, where the bundles divide into the Purkinje system. From here,
the wave of depolarization is distributed to the ventricular walls and initiates
ventricular contraction.

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