ECG Lead system
Dr. Ahamed Basha Abdul Bari
Professor of Physiology, CHRI.
Introduction
• Electrocardiography is a commonly used, noninvasive procedure for
recording electrical changes in the heart.
• Electrical activity of the heart is detected by electrodes attached to the
outer surface of the skin and recorded by a device (Electrocardiograph)
external to the body.
• Electrode - a conductor by which an electric current is conducted from
any medium, such as a cell, body, solution, or apparatus.
• Lead - two or more electrodes, connected to the electrocardiograph on
one end & attached at specific body sites. They are used to examine
electrical activity by monitoring changes in the electrical potential
between them.
Willem Einthoven – Inventor of Practical Electrocardiogram
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Basics of the ECG Leads
• Electrodes provide a three dimensional representation of cardiac
electrical activity; Each lead ‘looks’ at the same electrical event from
different spatial orientation
• Spread of depolarization wave towards the positive pole of the lead – will
give a positive deflection
• Spread of depolarization wave towards the negative pole of the lead – will
give a negative deflection
• Spread of depolarization wave perpendicular to the lead – will give a
biphasic deflection
Source: HTTPs://en.wikipedia.org/wiki/File:ECG_Vector.svg
Standard (conventional) 12 Lead ECG
ECG has 12 leads and
(Standard Surface ECG Leads)
• Bipolar Limb Leads
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• Unipolar Limb Leads
• Unipolar Chest Leads
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Standard (conventional) 12 Lead ECG (Cont…)
• Bipolar Limb Leads - L I, II and III
• Electrodes that form these signals are located on the limbs.
• Unipolar Limb Leads - aVR, aVL, and aVF (a - augmented)
• Derived from the same three electrodes as leads I, II, and III.
• Use Goldberger's central terminal (combination of inputs from two
limb electrodes) as their negative pole.
• Unipolar Chest Leads
• Precordial leads lie in the transverse (horizontal) plane, perpendicular
to the other Limb leads.
• Six precordial electrodes act as the positive poles for the six
corresponding precordial leads: (V1, V2, V3, V4, V5, and V6).
• Wilson's central terminal (center of the Einthoven triangle) is used as
the negative pole.
Einthoven’s Law
• Einthoven's triangle is an imaginary formation of three limb leads in a
triangle used in electrocardiography.
• In an ECG taken simultaneously with three limb leads at any given instant
the potential in lead II is equal to the algebraic sum of the
potentials in leads I and III.
• L2 =L1 + L3
Bipolar Limb Leads
Lead I Lead II Lead III
Left arm & Right arm Right arm & Left leg Left arm & Left leg
(Superior aspect of the (Right aspect of the heart) (Left aspect of the heart)
heart)
Right leg –
Earth
(Reference)
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Unipolar Limb Leads
• + ve to one limb
• - ve to the other two limbs through high resistance making the potential close to zero.
• Increases the voltage recorded
aVR - Right arm aVL - Left arm aVF - Left leg (foot)
Right leg –
Earth
(Reference)
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Unipolar Chest Leads
Name Electrode placement
V1 In the 4th intercostal space (between ribs
4 and 5) just to the right of the sternum.
V2 In the 4th intercostal space (between ribs 4
and 5) just to the left of the sternum.
V3 Between leads V2 and V4.
V4 In the 5th intercostal space (between ribs 5
and 6) in the mid-clavicular line.
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V5 Horizontally even with V4 in the
left anterior axillary line.
V6 Horizontally even with V4 and V5 in
the mid-axillary line.
Summary - Leads Placements
Source:
Source : https://en.wikipedia.org/wiki/File:Limb_leads_of_EKG.png https://commons.wikimedia.org/wiki/File:Precordial
_leads_in_ECG.png
Importance of various leads
• Each of the 12 ECG leads records the electrical activity of the heart from a
different angle, and therefore align with different anatomical areas of the
heart.
• Two leads that look at neighboring anatomical areas are said to be
contiguous.
Remember to SAIL through it
Septal leads V1 and V2
Anterior leads V3 and V4
Inferior leads II, III, aVF
Lateral leads I, aVL, V5 and V6
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Additional Lead placements
Right sided ECG electrode placement
• A complete set of right-sided leads is
obtained by placing leads V1-6 in a mirror-
image position on the right side of the
chest.
• The most useful lead is V4R (5th right
intercostal space in the mid-clavicular line).
• ST elevation in V4R has a sensitivity of
88%, specificity of 78% and diagnostic
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accuracy of 83% in the diagnosis of RV MI.
V4R ECG lead placement
• Use of a right sided precordial lead
(V4R) in the diagnosis of right
ventricular infarction which had
previously been thought to be
electrocardiographically silent.
• Diagnosis of right ventricular
involvement in inferior myocardial
infarction.
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Additional Lead placements
Posterior leads
• V7 – Left posterior axillary line, in the same
horizontal plane as V6.
• V8 – Tip of the left scapula, in the same
horizontal plane as V6.
• V9 – Left paraspinal region, in the same
horizontal plane as V6.
• Degree of ST elevation seen in V7-9 is
required to make the diagnosis of posterior
MI. Source : https://litfl.com/ecg-library/
Additional Lead placements
Lewis lead (S5-lead)
• To detect atrial activity and its relationship to
ventricular activity.
• Lewis lead placement
• Right Arm (RA) electrode on manubrium
• Left Arm (LA) electrode over 5th ICS, right
sternal border.
• Left Leg (LL) electrode over right lower
costal margin.
• Lewis Lead is read as Lead I on the ECG
• Observing flutter waves in atrial flutter Source : https://litfl.com/ecg-library/
Additional Lead placements
3-electrode system 5-electrode system
• Uses 3 electrodes (RA, LA and • Uses 5 electrodes (RA, RL, LA, LL
LL) and Chest).
• Monitor displays the bipolar leads
(I, II and III) • Monitor displays the bipolar leads
• To get best results – Place (I, II and III) and a single unipolar
electrodes on the chest wall lead (depending on position of
the chest lead (positions V1–6)).
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Additional Lead placements
Esophageal lead Intracardiac electrogram (ICEG)
• Inserted to a part of • ECG with some added intracardiac
the esophagus where the distance leads (that is, inside the heart)
to the approximately 35cm from
external nostril. • The standard ECG leads (external
• Atrial flutter leads) are I, II, III, aVL, V1, and V6.
• Wolff-parkinson-white
syndrome. • Two to four intracardiac leads are
added via cardiac catheterization.
• A record of changes in the electric
potentials of specific cardiac loci.
Lead II ECG – An Overview
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Disclaimer
• This presentation is to be used as an adjunct to other learning
methodologies and not a substitute for appropriate clinical training and
qualification
Acknowledgement & References
Prof. Prince. J Prof. P. S
Samuel Jeganathan
Thank you
