FACULTY OF CLINICAL

MEDICINE AND DENTISTRY

DEPARTMENT OF INTERNAL MEDICINE

TOPIC PRESENTATION:
ELECTROPHYSIOLOGY OF THE HEART
PRESENTED BY AINEMBABAZI PAUL MBChB
3.2
2021-08-07257
 Electrocardiography
• An electrocardiogram (ECG or EKG) is a graphical
representation of electrical activity generated by the heart.

• Electrocardiography is the method of recording of ECG.

• Electrocardiograph is the machine that records ECG, which

amplifies the voltages and gives a plot of voltage as a function
of time.
 Cont’d.
• The signals, detected by means of metal electrodes attached to the
extremities and chest wall, are amplified and recorded by the
electrocardiograph device.

• ECG leads (derivations) are configured to display the instantaneous

differences in potential between specific pairs of electrodes.

• The utility of the ECG derives from its immediate availability as a

noninvasive, inexpensive, and highly versatile test.

• In addition to its use in detecting arrhythmias and myocardial

ischemia, it may reveal findings related to life-threatening
metabolic disturbances or to increased susceptibility to sudden
cardiac arrest
 ELECTROPHYSIOLOGIC BACKGROUND
• 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 records only the depolarization (stimulation) and

repolarization (recovery) potentials generated by the “working”
atrial and ventricular myocardium
 Cont’d.
• The stimulus initiating the normal heartbeat originates in the
sinoatrial (SA) node which possesses spontaneous
automaticity. Spread of the depolarization wave through the
right and left atria induces contraction of these chambers.

• Next, the impulse stimulates specialized conduction tissues in

the atrioventricular (AV) nodal and His-bundle areas; together,
these two regions constitute the AV junction.

• The bundle of His branches into two main divisions, the right
and left bundles, which rapidly transmit depolarization wave
fronts in a synchronous way to the right and left ventricular
myocardium by way of the Purkinje fibers.
 Cont’d.
• The main left bundle fans out into left anterior and left
posterior fascicle subdivisions.

• The depolarization wave fronts then spread through the

ventricular wall, from endocardium to epicardium, triggering
coordinated ventricular contraction.

• Since the cardiac depolarization and repolarization waves have

directions and magnitudes, they can be represented by
vectors.
Schematic of the cardiac conduction system.
 Uses of ECG:
• ECG is useful for diagnosis of heart diseases. However, ECG
may be completely normal with a patient having organic heart
disease or may show some nonspecific abnormalities in normal
individuals.
• Therefore, ECG should be carefully interpreted with the clinical
features of the disease and with the reports of other
investigations.
ECG is useful for assessing:
1. Anatomical orientation of the heart.
2. Relative size of the chambers.
3. Disturbances of rhythm and conduction.
4. Ischemia of the myocardium, if present.
5. Location, extent and progress of myocardial infarction.
 TECHNICAL ASPECTS
• In modern electrocardiography, two types of ECG machines are
used:
(1) the string galvanometer; and
(2) the radioamplifier.
ECG is recorded on ECG paper fitted in the machine. ECG paper is
a strip of graph paper that contains vertical and horizontal lines 1
mm apart.

The horizontal axis represents time whereas the vertical axis

denotes amplitude.

There is a heavy line every 5 mm in both the planes. Thus, there

are small squares of 1 mm x 1 mm, and big squares of 5 mm x 5
mm.
 Cont’d.
• After every 5 big squares, the heavy vertical line overshoots
the margin.

• The ECG paper is a heat-sensitive plastic-coated paper. The

ECG is inscribed on this paper by a hot stylus.

• Conventional ECG is taken at a speed of 25 mm/s.

• One small square (1 mm) corresponds to 0.04 second, while

the big square (5 mm) is equivalent to 0.20 second.
 ECG Leads.
• An ECG lead is a pair of electrodes (electrical conductors) used
to detect the potential differences of the heart. The ECG leads
are broadly classified into two categories, the direct, and the
indirect leads

1. When a lead is directly applied to the surface of the heart, it

is called direct lead. These leads are used to record cardiac
activities during cardiac surgery.

2. When the leads are applied away from the heart (usually on
the body surface) to record the cardiac activities, they are called
indirect leads. Conventionally, ECG is recorded using indirect
leads. Indirect leads are limb leads, chest leads, and esophageal
leads.
 Cont’d.
• Usually, a twelve-lead recording is performed for complete
analysis of the ECG. The leads are connected in two planes
that are perpendicular to each other.
• One is the frontal plane that defines six limb leads and the
other is the transverse plane that defines six chest leads.
 Limb Leads
• Limb leads lie in the frontal plane. These are of two types: the
bipolar and the unipolar limb leads.
1. A bipolar lead records the potential difference between two
electrodes placed at different sites.

2. A unipolar lead is a pair of electrode giving the potential

difference between an exploring and an indifferent electrode (a
reference input).

3. The reference input comes from a combination of electrodes at

different sites that roughly gives a zero potential.
 Bipolar Limb Leads
• Three bipolar standard limb leads (leads I, II, and III) are the
original leads selected by Einthoven to record electrical
potential on the frontal plane.

• In the method of recording by bipolar leads, two electrodes are

placed on the body surface and the potential difference
between these two electrodes is recorded.

• The electrodes are attached to the right arm, left arm, and left
foot as indicated in the Einthoven triangle.

• Another electrode is applied to the right leg, which acts as a

ground wire to prevent external disturbances during recording
 Cont’d.
• Lead I : Between the right arm (negative electrode) and the
left arm (positive electrode).

• Lead II : Between the right arm (negative electrode) and the

left leg (positive electrode).

• Lead III : Between the left arm (negative electrode) and the
left leg (positive electrode).
Einthoven’s triangle.
 Einthoven Triangle.
• Einthoven triangle is an equilateral triangle with each
side representing the axis of one of the bipolar limb
leads. It is an inverted triangle with apex pointing
towards the groin and the base between two shoulders.
1. As body is a volume conductor, electrical attachment to an
arm is similar to the connection at the corresponding
shoulder joint, and attachment to either leg is similar to the
connection at the groin. Einthoven proposed certain
convention in analyzing the electrical activity of the heart.

2. The heart is considered to be present at the center of the

Einthoven triangle. Each corner of the triangle serves as the
location for an electrode for two leads to the ECG recorder.
Thus, three limbs of the triangle represent three leads
 Cont’d.
3. The convention proposed by Einthoven was that one
electrode causes an upward deflection on the recorder when it
is under the influence of a positive dipole (the concept of dipole
is discussed later in the chapter) relative to the other electrode.

4. Einthoven triangle is also used in calculation of mean QRS

axis of the heart
 Unipolar Limb Leads
• In the method of recording by unipolar leads, one electrode is the
active or recording electrode and the other one is the indifferent
electrode.
1. There are three unipolar limb leads: aVR, aVL, and aVF. In this, ‘a’
stands for augmentation of the leads. The potential recorded in aVL
is one-and-a-half times more than that recorded in VL, and similarly
for aVR and aVF. Therefore, these leads are called augmented
leads.

2. ‘V’ stands for unipolar, and R, L, and F indicate that the exploring
or active electrode is on the right arm, left arm, and left foot
respectively.

3. The other electrode, i.e. the indifferent electrode is connected to the

remaining two leads through a resistance coil.
 Cont’d.
For example, for recording of aVL, the active electrode is placed
on the left arm and the indifferent electrode is connected through
a high resistance to the other two electrodes placed on the left
foot and left arm.
• aVR: Between the right arm (positive electrode) and left
arm + left leg (negative electrode).

• aVL: Between the left arm (positive electrode) and right

arm + left leg (negative electrode).

• aVF: Between the left foot (positive electrode) and right

arm + left arm (negative electrode). Vector of
augmented limb lead = 3/2 vector of unaugmented limb
lead.
 Cont’d.

• aVR = VR – (VL + VF)/2

• 2aVR = 2VR – (VL + VF)
• Since VR + VL + VF = zero (Einthoven’s triangle),
• VR = – (VL + VF) 2aVR = 2VR + VR aVR = 3/2VR
 Chest Leads
• Chest leads or precordial leads lie in the transverse plane. These
are of two types: the unipolar and the bipolar chest leads.
• Unipolar Chest Leads There are six precordial leads that are used
routinely.
• These are V1 to V6 (‘V’ stands for unipolar). These leads employ
an exploring electrode on the chest surface.
• The reference or the indifferent electrode is connected to the
right arm, left arm and left leg through the high resistance, which
is called Wilson’s terminal that is maintained at zero potential.
• The right leg is connected with a grounding electrode to avoid
electrical interference. The position of the chest electrodes
(positive electrodes) on chest surface for a different lead is as
follows:
 Cont’d.
V1 : In the right fourth intercostal space at the right
border of the sternum.
V2 : In the left fourth intercostal space at the left
border of the sternum.
V3 : At the midpoint between V2 and V4.
V4 : In the left fifth intercostal space on the
midclavicular line.
V5 : In the left fifth intercostal space on the anterior
axillary line.
V6 : In the left fifth intercostal space on the midaxillary
line.
 Cont’d.
• There are other three chest leads (V7–V9) that are used on
special occasions:
V7 : In the left fifth intercostal space on the posterior
axillary line.

V8 : In the left fifth intercostal space on the posterior

scapular line.

V9 : In the left fifth intercostal space on the back just

left to the spine.
 NORMAL ECG
• The ECG tracing shows different waves, segments and
intervals as depicted from a lead II tracing
ECG Waves
• Waves are positive or negative deflections from baseline.
There are four waveforms:
1. P wave,
2. QRS complex,
3. T and
4. U waves.
Normal lead II ECG showing different waves.
 Normal electrocardiogram from a healthy male subject.

Sinus rhythm is present with a heart rate of 75 beats per minute. PR

interval is 160 ms; QRS interval (duration) is 80 ms; QT interval is 360
s; QTc (Framingham formula) is 391 ms; the mean QRS axis is about
+70°. The precordial leads show normal R wave progression with the
transition zone (R wave ≈ S wave) in lead V3.
 Cont’d.
Wave P wave is the first positive deflection in the ECG,
produced by atrial depolarization.
QRS Complex
• This consists of Q, R, and S waves. The QRS complex consists
of deflections produced by ventricular depolarization (Fig.
88.2B).
Q wave: Is the initial negative deflection in the QRS complex.
R wave: Is the positive deflection in the QRS complex.
S wave: Is the second negative deflection in the QRS
complex.
 Cont’d.
• T Wave T wave is the positive deflection produced by
ventricular repolarization.

• U Wave U wave is the final positive deflection in the ECG.

Normally, this wave is not always present. It occurs due to slow
repolarization of papillary muscle.
 ECG Segments
• Segments are isoelectric lines in ECG tracing. There are two
segments: PR segment and ST segment.
• PR Segment This lies between the end of the P wave and the
beginning of the QRS complex.
• ST Segment This lies between the end of the QRS complex
and the beginning of the T wave. The point where the QRS
complex ends and the ST segment begins is the J point.
• Elevation of J point suggests myocardial ischemia or infarction.
ECG showing ST segment elevation.
Criteria of right ventricular hypertrophy and its causes.
 ECG in myocardial infarction (MI):
• There are two types of MI. STEMI and NSTEMI
– STEMI Criteria
♦ ST elevation in >2 chest leads >2 mm elevation

♦ ST elevation in >2 limb leads >1 mm elevation

♦ Q wave > 0.04s (1 small square

ECG findings depending on the location of myocardial infarct.
Sequential ECG changes in STEMI:
 Non ST-elevation MI (NSTEMI)
– NSTEMI is also known as subendocardial or non Q-wave MI. In
a patient with acute coronary syndrome (ACS) in which the ECG
does not show ST elevation, NSTEMI (subendocardial MI) is
suspected if ECG shows T wave inversion (symmetrical,
arrowhead) with or without ST depression.

– An ST depression is more suggestive of myocardial ischemia

than infarction
 ECG Intervals
• Intervals usually include waves and segments.
PR Interval Definition: This is the interval between the
beginning of the P wave and the beginning of the QRS complex.
• Normal duration: The range of PR interval is from 0.12 to
0.20 second (average 0.18 s).
• PR interval shortens as the heart rate increases from the
average of 0.18 s at the rate of 70 to 0.14 s at the rate of 130.
Significance: This represents atrial depolarization and
conduction through AV node.
 QRS Interval (QRS Duration)
• Definition: This is the interval of the QRS complex. It is
measured from the beginning of the Q wave (or R wave if Q
wave is absent) to the J point.
• Normal duration: The normal range is from 0.08 to 0.10
second. Significance: This represents ventricular
depolarization. The atrial repolarization also occurs in this
period.
 QT Interval
• Definition: This is the interval for QRS complex, ST segment
and T wave.

• It is measured from the beginning of the QRS complex to the

end of the T wave.

• Normal duration: The normal range is between 0.40 and 0.43

second.

Significance: This represents ventricular depolarization and

ventricular repolarization. It corresponds to the duration of
electrical systole.
 ST Interval
• Definition: This is the interval between the J point and the
end of T wave. It is calculated by deducting QRS interval from
QT interval.

• Normal duration: The average duration is 0.32 second.

• Significance: This represents ventricular repolarization.

 Cont’d.
• PP Interval This is the interval measured between either the
peak or the beginning of two successive P waves.

• PP interval is measured for calculation of the atrial rate. RR

Interval This is the interval between two successive R waves.
It is measured between the peaks of two successive R waves.

• RR interval is measured for calculating the heart rate (the

ventricular rate).
 Systematic Interpretation of ECG
• A routine screening of the ECG needs stepwise examination of the
ECG.
1. What is the heart rate? What is the atrial rate and what is the
ventricular rate?
2. Is the rhythm regular or irregular?
3. What is the mean cardiac vector?
4. Are the P waves normal? Do the P waves have a fixed relation to
the QRS complexes?
5. What is the duration of PR interval? What are the duration,
amplitude and configuration of the QRS complex?
6. Is the ST segment isoelectric?
7. Are the T waves normal?
8. What is the duration of QT interval? Is the QTc appropriate for the
heart rate (QTc is the QT interval corrected for the rate)?
 Heart Rate
• In interpretation of ECG, heart rate should be calculated first.
The comment should be made on both atrial and ventricular
rates. Usually, the heart rate means the ventricular rate.
• At a paper speed of 25 mm/s, the atrial rate per minute is
calculated by dividing 1500 with PP interval (in mm).
• Similarly, ventricular rate per minute is calculated by dividing
1500 with RR interval (in mm). Normally, the RR interval is
equal to the PP interval. But, sometimes ventricular rate may
be different from the atrial rate.
 Calculation of the ventricular rate
• When RR interval is irregular: When RR interval is irregular as
seen in atrial fibrillation, the number of QRS complexes is
counted over 5 seconds (125 mm) in the rhythm strip and this
number is multiplied by 12 to provide the number of QRS
complexes in 60 seconds (1 minute). This enables the
measurement of the average ventricular rate.
• The normal heart rate is 60 to 100 per minute.
 Abnormalities of Heart Rate
Bradycardia
Heart rate < 60/min is called bradycardia.
1. Sinus bradycardia Sinus
bradycardia
− Athletes
− Sick sinus syndrome
− Drugs (e.g. beta blockers)
− Obstructive jaundice
− Raised intracranial pressure
− Myxedema
2. Junctional (nodal) rhythm
 Cont’d.
Tachycardia
• Heart rate > 100/min is called tachycardia.
1. Sinus tachycardia
− Anxiety
− Fever
− Hypoxemia
− Thyrotoxicosis
− Cardiac failure
− Acute carditis
2. Ectopic (reentrant) tachycardia
 Cont’d.
3. Atrial premature beats
− Anxiety
− Excess tea or coffee intake
− Viral infections
− Rheumatic heart disease
− Digitalis toxicity
− Cardiomyopathies
 Cont’d.
4. Paroxysmal supraventricular tachycardia
5. Atrial fibrillation
− Rheumatic heart disease with mitral stenosis
− Coronary artery disease
− Cardiomyopathies
− Thyrotoxicosis
6. Atrial flutter
− Rheumatic heart disease
− Coronary artery disease
 Cont’d.
7. Ventricular premature beats
8. Ventricular tachycardia
Axis of ECG.
 PATHOLOGICAL ECG
• ECG is useful in detecting four types of abnormalities:
1. Abnormal pattern of cardiac excitation resulting in different
types of arrhythmias.
2. Abnormalities of myocardium.

3. Cardiac abnormalities due to alteration in plasma electrolytes.

4. Cardiac involvement secondary to other diseases.

 Cardiac Arrhythmias
• Disorder of the property of rhythmicity of the heart is called
arrhythmia. Abnormalities of the rhythm should be better
termed as dysrrhythmia rather than arrhythmia.
• Clinically, cardiac dysrrhythmias can be broadly divided into
two categories: bradyarrhythmias (arrhythmias in which
cardiac rate is decreased) and tachyarrhythmias (type of
arrhythmias in which cardiac rate is increased).
• However, physiologically cardiac dysrrhythmias can be
divided into four categories depending on the functional site
affected:
• Disorders of SA node, Atrial arrhythmias, Ventricular
arrhythmias, and Conduction disorders.
 Disorders of SA Node
• The common disorders of SA node are sinus arrhythmia, sick
sinus syndrome, sinus tachycardia and sinus bradycardia.
Sinus Arrhythmia
Sinus arrhythmia is a normal physiological phenomenon
referred to the alteration in heart rate in respiratory cycles.
Heart rate increases in inspiration and decreases in expiration.
This is also called respiratory sinus arrhythmia. It is explained
by four mechanisms:
1. Alteration in autonomic activity: During inspiration,
sympathetic discharge increases, and during expiration,
vagal activity increases.
 Cont’d.
2. Activation of Bainbridge reflex: During inspiration,
increased venous return to the right atrium increases heart rate.
The decrease in intrathoracic pressure during inspiration,
increases right atrial filling and stretches the right atrium. Thus,
atrial tachycardia producing receptors are activated that produces
tachycardia. Right atrial stretching also stretches SA node, which
causes tachycardia.

3. Irradiation from inspiratory center: Increased irradiation

from inspiratory center to the vasomotor center during inspiration
increases the heart rate.

4. Activation of atrial stretch reflex: Increased venous return

during inspiration stimulates type B atrial stretch receptors. This
 Sick Sinus Syndrome
• Decrease in heart rate due to disease of SA node is called sick
sinus syndrome. Sinus Tachycardia When heart rate is more than
100/min in adult, the condition is called sinus tachycardia. Rarely
sinus tachycardia is more than 200/min. It is actually not a
primary arrhythmia.
Causes of sinus tachycardia are:
• Anxiety
• Fever
• Hypoxemia
• Thyrotoxicosis
• Cardiac failure
• Acute carditis
• Drugs like atropine
 Sinus Bradycardia
• When heart rate is less than 60/min, the condition is called
sinus bradycardia. This occurs due to suppression of SA node.
Causes of sinus bradycardia are:
• Strong athletes
• Sick sinus syndrome
• Drugs (e.g. beta blockers)
• Obstructive jaundice
• Raised intracranial pressure
• Myxedema