Electrocardiogram (ECG)
Israr Hussain Yousafzai
BS (Anesthesia) PGRT MSPH
Sr. RT, HMC Peshawar
Definitions
Electrocardiography
• The technique by which electrical activities of the heart are studied
• The spread of excitation through myocardium produces local
electrical potential which flows through the body
• This current can be picked up from surface of the body by using
suitable electrodes (ECG leads)
• This technique was discovered by Dutch physiologist, Einthoven
Willem, who is considered the father of ECG
Definitions
Electrocardiograph
• The instrument by which
electrical activities of the
heart are recorded
Electrocardiogram
• The graphical representation
of electrical activities of the
heart, which occur prior to
the onset of mechanical
activities
Uses of ECG
ECG is useful diagnostic for the following: (RAHI)
1. Heart rate
2. Heart rhythm
3. Abnormal electrical conduction
4. Hypertrophy of heart chambers
5. Poor blood flow to heart muscle (ischemia)
ECG Grid
• The paper that is used for recording ECG
• ECG machine records these signals on a moving ECG paper
• ECG paper has horizontal and vertical lines at regular intervals of 1
mm (small box)
• Every 5th line (5 mm) is thickened (large box) time (s)
• X-axis: 1 mm = 0.04 s, 5 mm = 0.20 s
• Y-axis: 1 mm = 0.1 mV, 5 mm = 0.5 mV
• Speed of paper through the machine is 25 mm/s amplitude (mV)
• If heart rate is very high, speed will be 50 mm/s
ECG Leads
• ECG is recorded by placing series of electrodes on the surface of the
body
• These are called ECG leads that connected to the ECG machine
• Electrodes are fixed on the limbs and heart is said to be in the center
of an imaginary equilateral triangle
• This triangle is called Einthoven triangle
• ECG is recorded in 12 leads, which are:
I. Bipolar leads
II. Unipolar leads
Bipolar Limb Leads
• Also known as standard limb leads
• Two electrodes are connected to obtain a leads
• Both electrodes are active
• One electrode is positive and the other one is negative
1. Limb lead I (Right arm –ve, left arm +ve)
2. Limb lead II (Right arm –ve, left leg +ve)
3. Limb lead III (Left arm –ve, left leg +ve)
Unipolar Leads
• One electrode is active and the other one is an indifferent
• Active electrode is positive and the indifferent act as a negative
• Unipolar leads are of two types:
1. Unipolar limb/augmented leads
I. aVR (right arm A, left arm + left leg I)
II. aVL (left arm A, right arm + left leg I)
III. aVF (left leg A, upper limbs I)
2. Unipolar chest leads (V1-V6)
Unipolar Chest Leads
• Also called ‘V’ leads or precardial leads (V1 , V2 , V3 , V4 , V5 and V6)
• Indifferent electrode is obtained by connecting the three limbs
• Active electrode is placed on six points over the chest:
V1 : Over 4th intercostal space near right sternal margin
V2 : Over 4th intercostal space near left sternal margin
V3 : In between V2 and V4
V4 : Over left 5th intercostal space on the mid clavicular line
V5 : Over left 5th intercostal space on the anterior axillary line
V6 : Over left 5th intercostal space on the mid axillary line
Normal ECG
Normal ECG consists of following:
• Waves: P, Q, R, S and T
• Segments: ST
• Intervals: PR, QT and RR
• Complexes:
1. ‘P’ wave, the atrial complex
2. ‘QRS’ complex, the initial ventricular complex
3. ‘T’ wave, the final ventricular complex
4. ‘QRST’, the ventricular complex
P Wave 0.1-0.12 mV
• Positive, also called atrial complex
• Produced due to the depolarization of atrial musculature 0.1 s
• Depolarization spreads from SA node to all parts of atrial musculature
• Atrial repolarization is not recorded as it merges with ventricular
repolarization
• Variation in the duration, amplitude and morphology helps in the diagnosis
of several cardiac problems i.e.:
1. Right atrial hypertrophy: Tall (> 2.5 mm)
2. Left atrial hypertrophy: Tall and M shaped
3. Hyperkalemia: Absent or small
4. Atrial fibrillation: Absent
QRS Complex
• Initial ventricular complex
• Q wave is a small negative, continued as tall
positive R wave, followed by a small negative S
wave
• Produce due to depolarization of ventricular
musculature
Q = depolarization of basal portion of inter ventricular
septum
R = depolarization of apical portion of inter ventricular
septum and ventricular muscle
S = depolarization of basal portion of ventricular muscle
Significance 1 mV
Variation in the duration,
amplitude and morphology helps
in the diagnosis of several cardiac
problems such as:
0.1-0.2mV 0.4 mV
1. Bundle branch block: prolonged
or deformed
2. Hyperkalemia: prolonged
0.08-0.10 s
T Wave
• Positive, final ventricular complex
• Produce due to the repolarization
of ventricular musculature
0.3 mV
• Significance:
1. Acute myocardial ischemia: Hyper
acute wave
2. Old age, hyperventilation, anxiety,
myocardial infarction, 0.2 s
hypokalemia and LVH: small, flat
or inverted
3. Hyperkalemia: tall and tented
U Wave
• Not always seen
• Produce due to repolarization of papillary muscle
• Appearance: Hypercalcemia, thyrotoxicosis and hypokalemia
• Myocardial ischemia: Inverted
P-R Interval
• Interval between the onset of P wave to onset of Q wave
• Indicate atrial depolarization and time taken for conduction of
impulses through AV node
• Prolonged in bradycardia and 1st degree heart block
• Shortened in tachycardia
0.18 (0.12 to 0.2) s
Q-T Interval
• Interval between the onset of Q wave to end of T wave
• Indicates ventricular depolarization and repolarization
• i.e. it signifies the electrical activity in ventricles
1. Prolonged in myocardial infarction, myocarditis, hypocalcemia and
hypothyroidism
2. Shortened in Hypercalcemia
0.40-0.42 s
R-R Interval
• Time interval between two consecutive R waves.
• Shows duration of one cardiac cycle
• Measurement of R-R interval helps to calculate:
1. Heart rate
2. Heart rate variability
Calculation of Heart Rate
• Count large boxes b/w RR
1. If 1 large box is present, HR = 300
2. If 2 large box is present, HR = 150
3. If 3 large box is present, HR = 100
4. If 4 large box is present, HR = 75
5. If 5 large box is present, HR = 60
6. If 6 large box is present, HR = 50
• Number of R waves per unit time
1. HR = # R in 6 s X 10 (30 large boxes = 6 s)
2. HR = 1500 / # small boxes bw RR
3. HR = 300 / # large boxes bw RR
Heart Rate Variability
• Beat to beat variations
• Normally ECG of healthy individuals exhibits some periodic variation
in R-R intervals called respiratory sinus arrhythmia (RSA)
• As it fluctuates with the phases of respiration
• R-R interval decreases during inspiration and increases during
expiration
• If HRV decreases it will indicate HTN, DM and psychiatric problems
S-T Segment 0.8 s
• Time interval between the end of S to onset of T wave
• It is an isoelectric period
• The point where S-T segment starts is called J point
• Significance:
1. Elevation occurs in anterior myocardial infarction, left bundle branch block
2. In athletes, it is usually elevated
3. Depression occurs in acute myocardial ischemia, posterior myocardial
infarction, ventricular hypertrophy and hypokalemia
4. Prolonged in hypo, shortened in Hypercalcemia
