ECG

Dr. Devendra Chhayala

Introduction
Introduction
Introduction
 Electrocardiography is the
technique by which
electrical activities of the
heart are studied.
 The spread of excitation
through myocardium
produces local electrical
potential.
Introduction
 This low-intensity
current flows through
the body, which acts as
a volume conductor.
 This current can be
picked up from surface
of the body by using
suitable electrodes and
recorded in the form of
electrocardiogram.
Introduction
 Introduction
 Electrocardiogram
 Electro-
cardiograph  Electrocardiogram is
the record or
 Electrocardiog graphical registration
raph is the of electrical activities
instrument of the heart, which
(machine) by occur prior to the
onset of mechanical
which
activities. It is the
electrical summed electrical
activities of activity of all cardiac
the heart are muscle fibers
recorded. recorded from
surface of the body.
Introduction
 Electrocardiogram is a graph obtained
when the electrical potentials of an
electrical field originating in the heart
are recorded at the body surface. It has
many limitations like
 It records only projection of voltage on
a particular lead.
 It is very approximate; lead positions
are not true representation of axis.
 It has many technical errors.
 Introduction
 Despite limitations it has
tremendous clinical utility; it
provides information that is
essential for diagnosis and therapy
of many cardiac conditions.
 It reflects anatomic,
haemodynamic, molecular, ionic
and drug induced abnormalities of
heart.
Einthoven Triangle and Einthoven
Law
 Einthoven triangle is defined as an
equilateral triangle that is used as a
model of standard limb leads used
to record electrocardiogram.
 Heart is presumed to lie in the
center of Einthoven triangle.
 Electrical potential generated from
the heart appears simultaneously
on the roots of the three limbs,
namely the left arm, right arm and
the left leg.
ECG Leads
 ECG is recorded by placing series
of electrodes on the surface of the
body. These electrodes are called
ECG leads and are connected to
the ECG machine. Electrodes are
fixed on the limbs.
 ECG is recorded in 12 leads, which
are generally classified into two
categories.
 1. Bipolar leads
 2. Unipolar leads.
ECG Leads – Bipolar Limb Leads
 Bipolar limb leads are otherwise
known as standard limb leads.
 Two limbs are connected to obtain
these leads and both the electrodes
are active recording electrodes, i.e.
one electrode is positive and the
other one is negative.
 Standard limb leads are of three
types:
 Limb lead I
 Limb lead II
 Limb lead III.
ECG Leads
ECG Leads – Unipolar Leads
 In Unipolar leads one electrode is
active electrode and the other one
is an indifferent electrode.
 Active electrode is positive and the
indifferent electrode is serving as a
composite negative electrode.
 Unipolar leads are of two types:
 Unipolar limb leads
 Unipolar chest leads.
ECG Leads – Unipolar Leads
 Unipolar Limb Leads: Unipolar
limb leads are also called augmented
limb leads or augmented voltage
leads.
 Active electrode is connected to one of
the limbs.
 Indifferent electrode is obtained by
connecting the other two limbs
through a resistance.
 Unipolar limb leads are of three types:
 aVR lead
 aVL lead
ECG Leads – Unipolar Leads
 Unipolar Chest Leads:
 Chest leads are also called ‘V’ leads
or precardial chest leads. Indifferent
electrode is obtained by connecting
the three limbs, viz. left arm, left leg
and right arm, through a resistance of
5000 ohms. Active electrode is placed
on six points over the chest. This
electrode is known as the chest
electrode and the six points over the
chest are called V1 , V2 , V3 , V4 , V5
and V6 . V indicates vector, which
shows the direction of current flow.
ECG Leads – Unipolar Leads
 Unipolar Chest Leads:
 Position of chest leads:
 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.
m
Leads +ve input -ve input

Bipolar limb lead

I LA RA

II LL RA

III LL LA

Augmented unipolar limb leads

aVR RA LA+LL

aVL LA RA+LL

aVF LL LA+RA

Precordial leads
Wilson central terminal
V1 Right sternal margin 4th ICS
(LA+RA+LL)
V2 Left sternal margin 4th ICS DO

V3 Midway between V2 and V4 DO

V4 Left midclavicular line 5th ICS DO

V5 Left ant. axillary line 5th ICS DO

V6 Left mid. axillary line 5th ICS DO

Electrocardiographic Grid
 The paper that is used for
recording ECG is called ECG paper.
 ECG machine amplifies the
electrical signals produced from
the heart and records these signals
on a moving ECG paper.
 Electrocardiographic grid refers to
the markings (lines) on ECG paper.
ECG paper has horizontal and
vertical lines at regular intervals of
1 mm. Every 5th line (5 mm) is
thickened.
Duration
 Time duration of different
ECG waves is plotted
horizontally on X-axis.
 On X-axis
 1 mm = 0.04 second
 5 mm = 0.20 second
Amplitude
 Amplitude of ECG waves is
plotted vertically on Y-axis.
 On Y-axis
 1 mm = 0.1 mV
 5 mm = 0.5 mV „
Axis
Axis
Speed of the Paper
 Movement of paper through the
machine can be adjusted by two
speeds, 25 mm/second and 50
mm/ second.
 Usually, speed of the paper during
recording is fixed at 25
mm/second.
 If heart rate is very high, speed of
the paper is changed to 50
mm/second.
Sensitivity:
 Voltage is measured along the
vertical axis, a 10 mm deflection
is equivalent to 1 mV.
 When ECG complexes are too
large, the sensitivity can be
halved so that a 1 mV deflection
is equivalent to 5 mm.
Sensitivity:
 There is a provision to change
the sensitivity in special
circumstances; when ECG
complexes are too small, the
sensitivity can be doubled so that
a 1 mV deflection is equivalent to
20 mm.
Time & Voltage
Paper Speed
Paper Speed
Paper Speed
P Wave
 The P wave is the deflection produced by atrial
depolarisation.
 Normal P wave duration does not exceed 0.10 sec
and not more than 2.5 mm tall.
 Normally upright in I, II, aVF, and V3 to V6.
 Inverted in aVR
 Biphasic in III, aVL, and V1 & V2.
 P wave morphology is best studied in II and V1.

PR Interval:
 Normal PR interval varies from 0.12 to 0.20 sec.
 QRS Complex

 QRS complex is the deflection produced by ventricular

depolarisation.
 Amplitude of QRS complex in each limb lead should be
5mm or more and in each Precordial lead should
10mm or more.
 ECG is termed as low voltage below these values.
 Normal QRS complex duration does not exceed 0.11
sec.
 R wave is dominant in I, II, V4 to V6.
 S wave may be dominant in III, aVR and V1 V2.
 Either R or S may dominant in III, aVL, aVF and V 3
depending on QRS axis.
 QS complex is term used when the entire QRS
complex is negative without any positive deflection.
 ST Segment
 ST segment and T waves are produced
by ventricular repolarisation.
 The normal ST segment is isoelectric
but ST depression <0.5 mm in any
lead is not considerable to be
abnormal.
 ST segment elevation up to 1 mm in
limb leads and 2 mm in V1 to V4 may
be normal.
T Wave
 Normal T waves are upright in I, II, V4 to V6.
 Inverted in aVR.
 Upright, inverted or biphasic in III, aVL, V1 V2
V3 .

QT Interval:
 The QT interval varies from 0.35 sec to 0.44
sec, its upper limit is 0.42 in males and 0.43
in females. QT interval varies with heart rate
and therefore a correction for heart rate is
done by Bazett’s formula

QT (s)
QTc =-----------------------------
 U Wave
 It is a positive deflection which comes
after T wave and precedes the P wave
of the next cycle.
 It is possibly produced as a result of
slow repolarisation of the purkinje’s
fibre, the interventricular septum and
the papillary muscle.
 Many a time, the U wave is not
evident in ECG.
 It is usually best seen in lead V2 to V4.
 +ve / -
Duratio Amplitud Inver ve /
Wave Upright
n e ted biphasi
c / flat
I II aVF III aVL
0.1 0.1 – 0.12
P wave V4 V5 aVR V1 V2
second mV
V6 V3
QRS 0.08 - Q 0.1 – 0.2
Comple 0.1 mV
x Second
Larger
R 1 mV
R wave in V5
and V6
Larger
S wave S 0.4 mV in V1
and V2
III aVF
0.2 I II V5 aVL V1
T wave 0.3 mV aVR
second V6 V2 V3
V4
Normal Time Duration
Interval Time
P –R interval 0.18 second

Q – T interval 0.35 – 0.45 second

S – T interval 0.08 second

R – R interval 0.8 second

Cardiac cycle
 Atrial Events: Atrial events are
divided into two divisions
 Atrial systole = 0.11 (0.1) sec
 Atrial diastole = 0.69 (0.7) sec. „
 Ventricular Events: Ventricular
events are divided into two divisions
 Ventricular systole = 0.27 (0.3)
sec
 Ventricular diastole = 0.53 (0.5)
sec
Cardiac Cycle
 Ventricular Systole
 Isometric contraction = 0.05 sec
 Ejection period = 0.22 sec
 Total = 0.27
sec
 Ventricular Diastole
 Protodiastole = 0.04 sec
 Isometric relaxation = 0.08 sec
 Rapid filling = 0.11 sec
 Slow filling = 0.19 sec
 Last rapid filling = 0.11 sec
 Total = 0.53 sec
Cardiac Cycle
Heart Rate Calculation
Through ECG
Heart Rate Calculation Through ECG
Wave Counting
Cardiac Axis
Cardiac Axis
Cardiac Axis
Mean QRS Axis In
Frontal Plane

 The mean QRS vector is the

approximation of all main QRS vector due
to activation of the heart in the frontal
plane.
 It can be measured from all frontal plane
leads.