ElectroCardioGraphy

By
Dr. Omprakash sah
Medical Officer
NAMS, Bir Hospital
1
ECG = Electrocardiogram
Is graphical representation of electrical activity of
the heart
Each event has a distinctive waveform, the study of
which can lead to greater insight into a patient’s
cardiac pathophysiology.

2
 History
• 1842- Carlo Matteucci -electricity is a/w hrt beat

• 1876- Marey - electric pattern of frog’s heart

• 1895 - William Einthoven - invention of EKG

• 1906- Einthoven diagnoses some heart problems

• 1924 - Noble prize - Einthoven for EKG

(Italian realized , irish analysed ,
Dutch,credited for)
3
 History

• 1938 -AHA & Cardiac society of great Britain defined

position of chest leads

• 1942- Goldberger increased Wilson’s Unipolar lead

voltage by 50% & made Augmented leads

4
Photograph of a complete Electrocardiograph Showing
the manner in which the electodes are attached to the
patient – in this case hands and one foot being immersed
in the Jars of Salt solution
5
• Review of the conduction system/
Electrophysiology
• ECG leads
• ECG waveforms and intervals
• Determining heart rhythm / rate
• Determining QRS axis

6
Conduction system
Electrophysiology

7
8
 Cardiac Electrophysiology

• Electrical activity is governed by multiple

transmembrane ion conductance changes
• 3 types of cardiac cells

– 1. Pacemaker cells- SA node,

AV node (a back up pacemaker)

– 2.Specialised conducting tissue - Purkinje fibers

– 3. Cardiac myocytes
9
 Pacemakers of Heart

• SA Node - Dominant pacemaker -intrinsic rate of

60 - 100 beats/minute.

• AV Node - 40 - 60 beats/minute.

• Ventricular cells - 20 - 45 beats/minute.

10
 Cardiac Impulse
1. Cardiac impulse originates in the SA
node
2. Traverses the atria simultaneously –
no special conduction wires in atria
3. Reaches AV node – the check post –
so delay
4. Enters bundle of His and branches –
through specialized conducting wires
called Purkinje network - activates
both ventricles – quick QRS
5. First the septum from L to R, then
right ventricle and then the left
ventricle and finally the apex
6. Then the ventricles recover for next
impulse

11
12
Normal Sinus Rhythm （ NSR ）

o P wave rate 60 - 100 bpm with <10%

variation
o rate <60 = sinus bradycardia
o rate >100 = sinus tachycardia
o variation >10% = sinus arrhythmia

13
ECG Leads

14
Leads are electrodes which measure
the difference in electrical potential
between either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point

with zero electrical potential, located in the center of
the heart (unipolar leads)

15
The standard ECG has 12 leads:

Transverse plane (Chest Leads)

V1—V6 (Chest Leads)

Coronal plane (Limb Leads)

1. Bipolar leads — l , l l , l l l
2. Unipolar leads — aVL, aVR, aVF

16
Electrode Placement

17
 18

ECG Chest Leads

18
 ECG Chest Leads
Chest Lead Position
• V1 Fourth ICS, right sternal border
• V2 Fourth ICS, left sternal border
• V3 Equidistant between V2 and V4
• V4 Fifth ICS, left Mid clavicular Line
• V5 Fifth ICS Left anterior axillary line
• V6 Fifth ICS Left mid axillary line

19
20
 The Six Chest Leads

TRANSVERSE PLANE

21
 ECG Bipolar Limb Leads

• Standard ECG is recorded in 12 leads

• Six Limb leads – l , l l , l l l, aVR, aVL, aVF
• Six Chest Leads – V1 V2 V3 V4 V5 and V6
• l , l l , l l l, are called bipolar leads
• l between LA and RA
• l l between LF and RA
• l l l between LF and LA

22
 ECG Bipolar Limb Leads

- + - -

R L R L

F
+ +
F

23
24
 ECG Unipolar Limb Leads

• Standard ECG is recorded in 12 leads

• Six Limb leads –I, II, III, aVR, aVL, aVF
• Six Chest Leads – V1 V2 V3 V4 V5 and V6
• aVR, aVL, aVF are called unipolar leads
• aVR – from Right Arm Positive
• aVL – from Left Arm Positive
• aVF – from Left Foot Positive

25
 ECG Unipolar Limb Leads

+ +

R L

+ F

Lead aVR Lead aVL Lead aVF

26
27
The axis of a particular lead represents the
viewpoint from which it looks at the heart.

28
V1, V2: Septum
V5, V6: lateral wall
29
I aVL: high lateral wall
II, III, aVF: inferior wall
30
31
(Septum)

32
(Anterior Wall)

33
(Lateral Wall)

34
(Inferior Wall)

35
36
ECG Waves and intervals

37
• Segment – Straight line b/w waves
• Interval – wave + segment
• 3 waves, 2 intervals, 2 segments
38
• 3 distinct waves are produced during cardiac cycle

39
• P wave
caused by atrial depolarization

40
13-63
41
42
43
P Wave

• Always + in lead I & II

• Always - in lead aVR

• <3 small sqs - duration

• <2.5 small sqs - amplitude

• Best seen in lead II

44
P Wave

Depolarization of both atria

• Relationship b/w P & QRS - distinguish various

arrhythmias

• Shape & duration of P - indicate atrial enlargement

45
46
P Pulmonale

P MITRALE
47
P pulmonale
Peaked p waves (>2.5mm) indicate right atrial
enlargement.—due to pulmonary hypertension

P MITRALE （ P-sinistrocardiale ） :

• Broad, notched P waves (Bifid p waves)

• Results from overload of the left atrium regardless of the
cause
• and may occur independently of disease of the mitral
valve diseases such as mitral stenosis, mitral insufficiency ,
which could leads to Left ventricular hypertrophy

48
 PR INTERVAL

Onset of P wave to onset of QRS

• Normal = 0.12 - 2.0 sec

• Represents A to V conduction time (via His

bundle)

Prolonged PR interval indicate AV block

49
50
 Short PR Interval
• WPW Sx (Wolff-Parkinson White Syndrome)

Accessory pathway (Bundle of Kent) - early

activation of the ventricle (delta wave & short PR
interval)
Long PR Interval
• AV Block

51
Short PR Interval

52
• QRS complex
caused by ventricular depolarization

53
 Ventricular Depolarization
Includes
• Bundle of His
• Bundle Branches
– Right
– Left
• Septal
• Anterior
• Posterior
• Terminal Purkinjie fibers
54
 Ventricular Depolarization

• Ventricular Waves

– Q wave – 1st downward deflection after P wave

– Rwave – 1st upward deflection after Q wave

– R` wave – any second upward deflection

– S wave – 1st downward deflection after R wave

55
Ventricular depolarization

•Normal duration = 0.08 - 0.12 secs

Q wave >1/3 the height of R wave, >0.04 sec –

abnormal; may represent MI

56
V1, V2: rS R ／ S<1
V3, V4: RS R ／ S near 1
V5, V6: Rs R ／ S>1 57
ST Segment
• It starts at the J point (junction between the QRS complex and ST
segment) and ends at the beginning of the T wave
• Duration = 0.08 - 0.12 sec
•Flat, downsloping, or depressed ST segments may indicate coronary
ischemia.
•ST elevation may indicate myocardial infarction. 

58
• T wave
results from ventricular repolarization

59
13-63
T Wave

– “small to moderate” size +ve deflection wave

after QRS complex,
– Ht is 1/3rd - 2/3rd that of corresponding R wave

U Wave

– Septal repolarization (not always seen on ECG)

60
QT Interval

•Beginning of QRS to end of T wave

•Ventricular cycle, 40% of each cardiac cycle
• Normal QT is usually about 0.40 sec
• QT varies based on HR- faster HR ,shorter QT .
•Hence QTc.

61
 ECG Complex

• P Wave is Atrial contraction – Normal 0.12 sec

• PR interval is from the beginning of P wave to the
beginning of QRS – Normal up to 0.2 sec
• QRS is Ventricular contraction –Normal 0.08 sec
• ST segment – Normal Isoelectic (electric silence)
• QT Interval – From the beginning of QRS to the end
of T wave – Normal – 0.40 sec
• RR Interval – One Cardiac cycle 0.80 sec
62
63
Normal Sinus Rhythm

2. Each P wave is followed by a QRS

3. P wave is upright in leads I and II

64
ECG interpretation - step-by-step
• P – wave
• PR - interval
• QRS Complex
• ST Segment
• QT interval
• T wave

• Rate
• Rhythm
• Cardiac Axis

65
Heart Rate

66
 ECG Graph Paper
Y- Axis Amplitude in mill volts

X- Axis time in seconds

67
 ECG Graph Paper
Runs at a paper speed of 25 mm/sec
At a paper speed of 25 mm/s, one small block equals
0.04 s
X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec
Each small square is 0.04 sec (1 mm in size)
Each big square on the ECG represents 5 small squares
= 0.04 x 5 = 0.2 seconds
5 such big squares = 0.2 x 5 = 1sec = 25 mm (25mm/s)
One second is 25 mm or 5 big squares
One minute is 5 x 60 = 300 big squares
Voltage: Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1
Mv
Two big squares on Y-Axis=10 small block = 1 milli volt (mV)

68
RR Interval – One Cardiac cycle

Used to determine the heart rate

69
 Rate
Determination
No. of Big R – R Interval Rate Rate
Boxes Cal.
T
One 0.2 sec 60 ÷ 0.2 300 A
C
Two 0.4 sec 60 ÷ 0.4 150 H
Y
Three 0.6 sec 60 ÷ 0.6 100 N
O
Four 0.8 sec 60 ÷ 0.8 75 R
M
Five 1.0 sec 60 ÷ 1.0 60 A
L
Six 1.2 sec 60 ÷ 1.2 50 B
R
Seven 1.4 sec 60 ÷ 1.4 43 A
D
Eight 1.6 sec 60 ÷ 1.6 37 Y

70
 71

Rate Determination

QRS

Next
QRS

71
CALCULATING RATE
• Rule of 300

lead II, Look at # of square b/w one R-R interval.

300
Rate =
number of BIG SQUARE b/w R-R

Take the number of “big boxes” between neighboring QRS

complexes, and divide 300 into this number. The result will
be approximately equal to the rate

Although fast, this method only works for regular rhythms.

It may be easiest to memorize the following table:

73
 74

What is the Heart Rate ?

• To find out the heart rate we need to know

– The R-R interval in terms of # of big squares
– If the R-R intervals are constant
• In this ECG the R-R intervals are constant
• R-R are approximately 3 big squares apart
• So the heart rate is 300 ÷ 3 = 100

74
 75

What is the Heart Rate ?

75
 What is the Heart Rate ?

 To find out the heart rate we need to know

 The R-R interval in terms of # of big squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are constant
 R-R are approximately 4.5 big squares apart
 So the heart rate is 300 ÷ 4.5 = 67

76
 77

What is the Heart Rate ?

77
 What is the Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of Big Squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are not constant
 R-R are varying from 2 boxes to 3 boxes
 It is an irregular rhythm – Sinus arrhythmia
 Heart rate is 300 ÷ 2 to 3 = 150 to 100 approx

78
 What is the Heart Rate ?

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

79
10 Second Rule
As most ECGs record 10 seconds of rhythm per
page, one can simply count the number of beats
present on the ECG and multiply by 6 to get the
number of beats per 60 seconds.

This method works well for irregular rhythms.

80
 What is the Heart Rate ?

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

33 x 6 = 198 bpm 81
CALCULATING RATE
Rhythm irregular- # of beats in a 6-sec X by 10
1 2 3 4 5 6 7 8

There are 8 waves in this 6-seconds strip.

Rate = (Number of waves in 6-sec strips) x 10

= 8 x 10
= 80 bpm
Tests

83
(300 / 6) = 50 bpm

84
(300 / ~ 4) = ~ 75 bpm

85
(300 / 1.5) = 200 bpm

86
Normal Sinus Rhythm (NSR)

• Each P wave is followed by a QRS in a ratio of 1:1

• A heart rate of 60–100 beats per minute.
o rate <60 = sinus bradycardia
o rate >100 = sinus tachycardia
• PR interval is between .12 second and .20 second.
• QRS complex width should be less than .12 second.

87
Normal Sinus Rhythm (NSR)
the P waves are normal on the ECG

• Upright in leads I, II, and usually aVF

• Inverted in aVR

88
Determining ECG Axis

89
 Axis Determination & Deviation

• What is Axis?

– “The general direction of electrical impulses as

they travel through heart”
– “Sum total of all electrical currents generated by
ventricular myocardium during depolarization”
– Normally from upper Rt to lower Lt
 91

NW
QRS Axis
NE

SW SE
91
 QRS Axis
• Normal Axis - when it is downward and to the left – southeast quadrant –
from -30 to +90 degrees
• Right Axis – when it is downward and to the right – southwest quadrant –
from +90 to 180 degrees. Right Axis Deviation (RAD):
Right Ventricular Hypertrophy (RVH) — most common

• Left Axis – when it is upward and to the left – Northeast quadrant –

from -30 to -90 degrees, Left Axis Deviation (LAD)
Left ventricular hypertrophy (LVH) — most common

• Indeterminate Axis – when it is upward & to the right – Northwest

quadrant – from -90 to +180 , Extreme Axis Deviation

92
 Two Leads Method

Uses just 2 leads of the 6 limb leads

Look at Lead I & aVF (or III)

Axis normal –
I, III, and aVF all will be positive

94
 Axis Determination
ALL UPRIGHT MEET LEAVE

NORMAL RIGHT LEFT

95
 Axis Determination
Axis I III or aVF TIP

Normal Positive Positive Both Up

Right Negative Positive Meet

Left Positive Negative Leave

Peak-Peak: Right
96
1. Lead I & aVF divide thorax into quadrants,
 
 2. If Lead I & aVF (III) are both upright- Axis is
normal.

3. If lead I is upright & lead aVF is downward -

Axis is Left.

4. If lead aVF is upright & lead I is downward -

Axis is Rt

5. If both leads are downward - Axis is extreme

Right Shoulder & most often is Vent. Tachy

97
Tests

98
 99

What is the Axis ?

I
aVR

II aVL

III aVF

99
 ECG With Normal Axis

• Note the QRS voltages are positive and

upright in the leads - I, II, III and aVF
• I, II and aVF tell that it is downward
• I, aVL tell that it is to the left
• Downward and leftward is Normal Axis
• Normal QRS axis

100
 101

What is the Axis ?

II

III

101
 ECG With Right Axis
• Note the QRS voltages are positive and
upright in leads L2, L3
• Negative in Lead 1
• L2, L3 tell that it is downward
• L1 tells that it is not to the left but to right
• Downward and rightward is Right Axis
• See the Right –Meet criterion QRS in
L1 and L3 meet
• Right Axis Deviation - RAD

102
 103

What is the Axis ?

I aVR

II aVL

III aVF
103
 ECG With Left Axis

• Note the QRS voltages are positive

and upright in leads L1and aVL
• Negative in L2, L3 and aVF
• L1, aVL tell that it is leftward
• L2, L3, and aVF tell that it is not
down ward - instead it is upward
• Upward and Leftward is Left Axis
• See the Left - Leave criterion QRS
in L1 and L3 leave each
other
• Left Axis Deviation - LAD
104
 105

Normal Axis

105
More info for determing the axis
 AXIS

• Axis refers to general direction of heart's

depolarization wave front (or mean electrical
vector) in the frontal plane.

• In healthy conducting system - axis is related to

where the major muscle bulk of heart lies.
• William Einthoven developed a system capable of

recording small signals & recorded 1st ECG.

• Leads were based on Einthoven triangle a/w limb

leads.

• Leads put heart in middle of a triangle

ECG Signal
• Excitation begins at SA node

c
atrial walls
• Cannot propagate across the
boundary b/w atria & ventricle
• Resultant vector - in yellow
• Projections on Leads I, II and III
are all +ve
ECG Signal
• AV node located on A-V
boundary & provides
conducting path
• Delay - allow ventricles to fill.

• Excitation begins with septum

ECG Signal
• Depolarization Via bundle
branches towards apex
• Overall electric vector points
toward apex as both LV & RV
depolarize & begin to
contract
ECG Signal
• Depolarization of RV reaches
epicardium.

• LV wall is thicker &

continues to depolarize
ECG Signal
• As there is no compensating
electric forces on Rt, electric
vector reaches maximum size
& points Lt
• Note: atria ‘ve repolarized,
but signal is not seen
ECG Signal
• Depolarization front
continues to propagate to
back of LV wall
• Electric vector < in size as
there is less tissue
depolarizing
ECG Signal
• Depolarization of ventricles is
complete & the electric
vector has returned to zero
ECG Signal
• Ventricular REPOLARIZATION
begins from epicardium with
left being slightly dominant
ECG Signal
• Note that this produces an electric vector that is
directed as the depolarization traveling in opposite
direction

• Repolarization is diffuse & generates a smaller and

longer signal than depolarization
ECG Signal
• Upon complete
repolarization, hrt is ready to
go again & we record an ECG
trace
 ECG Information
• 12 leads allow tracing
of vector in all 3
planes
 Axis Determination & Deviation
• Why Axis Determination?

• Definitions

• Axis Quadrants

• Axis Determination

• Axis Deviation
 Axis Determination & Deviation

• What is Axis?

– “The general direction of electrical impulses as

they travel through heart”
– “Sum total of all electrical currents generated by
ventricular myocardium during depolarization”
– Normally from upper Rt to lower Lt
 Basics of 12 Lead ECG Vector

There are 3 basic "laws" of Electrocardiography.

• These "laws" ‘ve to do with the direction of flow of

electrical conduction in the heart or what we term
as vector.
 Basics of 12 Lead ECG Vector

1. Movement of electrical impulse towards +ve

electrode will result in a +ve deflection on ECG.
 
 

  - + =
 Basics of 12 Lead ECG Vector

2. Movement of electrical impulse toward –ve

electrode will result in a –ve deflection on the ECG.

- + =
 Basics of 12 Lead ECG Vector

3. Movement of electrical impulse perpendicular to a line

b/w +ve & -ve electrodes results in a bi-phasic (part
upright & part downward) deflection on ECG.

 
- + =
AXIS
 Basics of 12 Lead ECG's
Determining AXIS

Technique #1: Two Lead Method or Quadrant

Method

Uses just 2 leads of the 6 limb leads

Look at Lead I & aVF

AXIS

1. Lead I & aVF divide

thorax into quadrants,
(Lt, N , Rt, No Man's)
 
2. If Lead I & aVF are both
upright- Axis is normal.
 
3. If lead I is upright & lead
aVF is downward - Axis is
Left.
AXIS

4. If lead aVF is upright &

lead I is downward - Axis
is Rt

5. If both leads are

downward - Axis is
extreme Right Shoulder
& most often is Vent.
Tachy
 Axis Determination
• Quick Axis Determination
– Determine net deflection in Leads I & aVF (+ve /
-ve )

Lead I aVF
N axis

LAD

RAD

ERAD
The Quadrant Approach
Quadrant Approach: Example 1

/
Quadrant Approach: Example 2

/
Basics of 12 Lead ECG Vector

Method 2 : Three Lead technique

This method uses – 3 limb leads I, II, III to

determine axis of the QRS.
Axis Lead I Lead II Lead III

Normal Positive Positive Positive/Negative

Right axis Negative Positive Positive

deviation

Left axis Positive Negative Negative

deviation
 Basics of 12 Lead ECG Vector

Method # 3: Using Hexaxial Diagram to find degree of

Axis Deviation

This technique - most accurate( + or – 100 to 150)

 The Equiphasic Approach
1. See which lead contains - most equiphasic QRS.
2. Net vector is perpendicular this lead.
3. Examine QRS in whichever lead lies 90° away from
this lead.
4. If QRS in this 2nd lead is predominantly +ve, then
axis of this lead is approx same as net QRS axis.
5. If QRS is predominantly –ve , than net QRS- axis
lies 180° from axis of this lead.
 Basics of 12 Lead ECG Vector

Marked RAD -90°

-60°
-120°

aVR
LAD
-30°
Axis scale
-150° aVL

180° 0°
I

150°
30°

120° II
III 60°
Normal Axis
90° aVF
-30° to +100°
RAD
 Hexaxial Array for Axis Determination

Determination of
angle of HEART
AXIS in frontal
plain
Example 1

• Lead I

• Lead aVF

• Lead aVL
 Lead I

If lead I is mostly
+ve, the
axis must lie in Rt
½
of coordinate
system
 Lead AVF

If lead AVF is
mostly +ve, the
axis must lie in
the bottom ½ of
coordinate
system
 I AVF

Combining the 2
plots, we see
that axis must lie
in bottom
right hand
quadrant
I AVF AVL
Example 2
• Lead I

• Lead aVF

• Lead II
Example 2

Lead I

Lead I is
mostly -ve, the
axis must lie in
the Lt ½ of the
coordinate.
 Lead AVF

Lead aVF is
mostly +ve, the
axis must lie in
the bottom ½
of the coordinate
 I AVF

Combining the
two plots- axis
must lie in
bottom
Lt hand
quadrant (RAD)
I AVF II
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 Net voltage = 12
rectangle, then Since Lead III is the
connecting the origin most equiphasic

Net voltage = 7
of the coordinate lead and it is
system with the slightly more
opposite corner of positive than
the rectangle. A negative, this axis
protractor can then could be estimated
be used to measure at about 40o.
the deflection from
0.
CARDIAC AXIS
 CARDIAC AXIS

Positive

Positive

Positive

N Axis
CARDIAC AXIS
 CARDIAC AXIS

Positive

Negative

Negative

LAD
CARDIAC AXIS
CARDIAC AXIS

Negative

Positive

Positive

RAD
 CARDIAC AXIS

Cardiac Axis Causes

LAD Preg, obesity; Ascites, abdo distention,

tumour; LAHB, LVH, IWMI

RAD N finding in children & tall thin adults,

COPD, LPHB, Anterolateral MI.

North West Emphysema, Hyperkalaemia, Lead

transposition, Artificial cardiac pacing, VT
 References
• The ECG made easy-John R. Hampton
• An Introduction to Electrocardiography – Leo
Schamroth
• Marriot’s Practical Electrocardiography.
• www.ambulancetechnicianstudy.co.uk
• www.learntheheart.com
THANK YOU
?