Electrocardiography

Cardiovascular Department of the

Affiliated Hospital
Zuo Qi
 Outline
1. Electrophysiology
2. The conduction system
3. ECG lead system
4. ECG waveforms and intervals
5. Determining heart rate
6. Determining QRS axis
What is an electrocardiogram （
ECG or EKG ） ?
The electrocardiogram (ECG) is a
representation of the electrical
events of the cardiac cycle.
 Electrophysiology
Depolarization of the heart is the initiating
event for cardiac contraction. The electric
currents that spread through the heart are
produced by three components: cardiac
pacemaker cells, specialized conduction
tissue, and the heart muscle itself.
The ECG, however, records only the
depolarization (stimulation) and
repolarization (recovery) potentials
generated by the atrial and ventricular
myocardium. Since the cardiac
depolarization and repolarization waves
have direction and magnitude, they can
be represented by vectors.
However, the general principles of vector
analysis remain fundamental to understanding
the genesis of normal and pathologic ECG
waveforms. Vector analysis illustrates a
central concept of electrocardiography—that
the ECG records the complex spatial and
temporal summation of electrical potentials
from multiple myocardial fibers conducted to
the surface of the body.
This principle accounts for inherent limitations
in both ECG sensitivity (activity from certain
cardiac regions may be canceled out or may
be too weak to be recorded) and specificity
(the same vectorial sum can result from either
a selective gain or a loss of forces in opposite
directions).
The Normal Conduction System
The depolarization stimulus for the normal
heartbeat originates in the sinoatrial (SA) node,
or sinus node, a collection of pacemaker cells.
These cells fire spontaneously; that is, they
exhibit automaticity.
The first phase of cardiac electrical activation is
the spread of the depolarization wave through
the right and left atria, followed by atrial
contraction.
Next, the impulse stimulates pacemaker and
specialized conduction tissues in the
atrioventricular (AV) nodal and His-bundle
areas; together, these two regions constitute
the AV junction.
The bundle of His bifurcates into two main
branches, the right and left bundles, which
rapidly transmit depolarization wavefronts to
the right and left ventricular myocardium by
way of Purkinje fibers.
The main left bundle bifurcates into two
primary subdivisions, a left anterior fascicle
and a left posterior fascicle.

The depolarization wavefronts then spread

through the ventricular wall, from
endocardium to epicardium, triggering
ventricular contraction.
 How can we detect the
electrical signals generated by
the heart?
The signals are detected by means of metal
electrodes attached to the extremities and chest wall
and are then amplified and
recorded by the electrocardio-
graph. ECG leads actually
display the instantaneous
differences in potential between
these electrodes.
 ECG Leads
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)
The standard ECG has 12 leads, which are divided
into two groups: 6 limb (extremity) leads and 6 chest
(precordial) leads. The six limb leads are further
subdivided into three standard "bipolar" leads and
three augmented "unipolar" leads .

3 Standard Limb Leads (I, II, and III)

3 Augmented Limb Leads (aVR, aVL, and aVF)
6 Precordial Leads

The axis of a particular lead represents the viewpoint

from which it looks at the heart.
 Standard Limb Leads
Each bipolar lead measures the difference in potential
between electrodes at two extremities.
 Standard Limb Leads
The limb leads record potentials transmitted onto the
frontal plane.
 Augmented Limb Leads
The unipolar leads measure the voltage(V) at one locus
relative to an electrode(called the central terminal or
indifferent electrode) that has approximately zero potential.

The lowercase a:
indicates that these
unipolar potentials
are electrically
augmented by 50%.
The right leg
electrode functions
as a ground.
 All Limb Leads
The spatial orientation and polarity of the six frontal
plane leads is represented on the hexaxial diagram.
 Precordial Leads
the chest leads record potentials transmitted onto the
horizontal plane.
V1--4th intercostal space,
right sternum
V2 --4th intercostal space,
left sternum
V3--5th intercostal space,
left sternum
V4--5th intercostal space,
centered on clavicle
V5--5th intercostal space,
left of V4
V6--5th intercostal space,
under left arm
Precordial Leads
 Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III -

(standard limb leads)

Unipolar aVR, aVL, aVF V1-V6

(augmented limb leads)
Arrangement of Leads on the ECG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
Together, the frontal and horizontal plane
electrodes provide a three-dimensional
representation of cardiac electrical activity.
Each lead can be likened to a different
camera angle "looking" at the same events—
atrial and ventricular depolarization and
repolarization—from different spatial
orientations.
The conventional 12-lead ECG can be
supplemented with additional leads under
special circumstances. For example, right
precordial leads V3R, V4R, etc., are useful in
detecting evidence of acute right ventricular
ischemia. Bedside monitors and ambulatory
ECG (Holter) recordings usually employ only
one or two modified leads.
Waveforms and Intervals
The electrocardiogram is ordinarily recorded
on special graph paper which is divided into
1-mm2 gridlike boxes.
Since the ECG paper speed is
generally 25 mm/s, the smallest
(1 mm) horizontal divisions
correspond to 0.04s (40 ms),
with heavier lines at intervals
of 0.20 s (200 ms).
Vertically, the ECG graph measures the
amplitude of a given wave or deflection (1 mV =
10 mm with standard calibration).
The ECG waveforms are labeled
alphabetically, beginning with the P wave,
which represents atrial depolarization.

The QRS complex represents ventricular

depolarization, and the ST-T-U complex (ST
segment, T wave, and U wave) represents
ventricular repolarization.
The J point is the junction between the end of
the QRS complex and the beginning of the
ST segment.

Atrial repolarization is usually too low in

amplitude to be detected, but it may become
apparent in such conditions as acute
pericarditis or atrial infarction.
There are four major ECG intervals: R-R, PR,
QRS, and QT.

The heart rate (beats per minute) can be

readily computed from the interbeat (R-R)
interval by dividing the number of large (0.20
s) time units between consecutive R waves
into 300 or the number of small (0.04 s) units
into 1500.
The PR interval measures the time (normally
120–200 ms) between atrial and ventricular
depolarization, which includes the physiologic
delay imposed by stimulation of cells in the
AV junction area.

The QRS interval (normally 100-110 ms or

less) reflects the duration of ventricular
depolarization.
The QT interval includes both ventricular
depolarization and repolarization times and
varies inversely with the heart rate. A rate-
related ("corrected") QT interval, QTc, can be
calculated as and normally is 0.44 s. (Some
references give QTc upper normal limits as
0.43 s in men and 0.45 s in women.)
The QRS complex is subdivided into specific
deflections or waves. If the initial QRS
deflection in a given lead is negative, it is
termed a Q wave; the first positive deflection
is termed an R wave. A negative deflection
after an R wave is an S wave. Subsequent
positive or negative waves are labeled R' and
S', respectively. Lowercase letters (qrs) are
used for waves of relatively small amplitude.
An entirely negative QRS complex is termed
a QS wave.
 Determining the Heart Rate
Rule of 300

10 Second Rule
 Rule of 300
Take the number of “big boxes” between
neighboring QRS complexes, and divide this
into 300. The result will be approximately
equal to the rate

Although fast, this method only works for

regular rhythms.
 Rule of 300
It may be easiest to memorize the following table:

# of big boxes Rate

1 300
2 150
3 100
4 75
5 60
6 50
What is the heart rate?
What is the heart rate?

(300 / 6) = 50 bpm
What is the heart rate?
What is the heart rate?

(300 / ~ 4) = ~ 75 bpm
What is the heart rate?
What is the heart rate?

(300 / 1.5) = 200 bpm

 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.

What is the heart rate?
What is the heart rate?

33 x 6 = 198 bpm
 The QRS Axis

The QRS axis represents the net overall

direction of the heart’s electrical activity.

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e. hemiblocks)
 The QRS Axis
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to +90°.
-30° to -90° is referred to as a
left axis deviation (LAD)
+90° to +180° is referred to as
a right axis deviation (RAD)
 Determining the Axis

The Quadrant Approach

The Equiphasic Approach

 Determining the Axis

Predominantly Predominantly Equiphasic

Positive Negative
 The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine if they are predominantly
positive or predominantly negative. The combination
should place
the axis into
one of the 4
quadrants
below.
 The Quadrant Approach
2. In the event that LAD is present, examine
lead II to determine if this deviation is
pathologic. If the QRS in II is
predominantly positive, the LAD is non-
pathologic (in other words, the axis is
normal). If it is predominantly negative, it
is pathologic.
Quadrant Approach: Example 1

Negative in I, positive in aVF  RAD

 Quadrant Approach: Example 2

Positive in I, negative in aVF  Predominantly positive in II 

Normal Axis (non-pathologic LAD)

 The Equiphasic Approach
1. Determine which lead contains the most
equiphasic QRS complex. The fact that
the QRS complex in this lead is equally
positive and negative indicates that the net
electrical vector (i.e. overall QRS axis) is
perpendicular to the axis of this particular
lead.
 The Equiphasic Approach
2. Examine the QRS complex in whichever
lead lies 90° away from the lead identified
in step 1. If the QRS complex in this
second lead is predominantly positive,
than the axis of this lead is approximately
the same as the net QRS axis. If the QRS
complex is predominantly negative, than
the net QRS axis lies 180° from the axis of
this lead.
Equiphasic Approach: Example 1

The Alan E. Lindsay ECG Learning Center ; [Link]

Equiphasic in aVF  Predominantly positive in I  QRS axis ≈ 0°

Equiphasic Approach: Example 2

The Alan E. Lindsay ECG Learning Center ; [Link]

Equiphasic in II  Predominantly negative in aVL  QRS axis ≈ +150°

The clinical utility of the ECG derives from
its immediate availability as a noninvasive,
inexpensive, and highly versatile test.

What types of pathology can we identify

and study from ECGs?
The main types ：
Arrhythmias
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances (i.e.
hyperkalemia, hypokalemia)
Drug toxicity (i.e. digoxin and drugs which
prolong the QT interval)