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Dr. Felix James, BHMS, M.D


Electrocardiogram (ECG) is one of the time tested and reputable diagnostic

device that gives objective evidence regarding the normal and altered functions of the
heart. To know that one's ECG is within normal limits gives a great sigh of relief to
patients as well as the physicians. Having clarity about the basic concepts of ECG help
us to arrive at definite conclusions regarding the functions of the heart. We have to be
cautious about the fact that not all cardiac abnormalities get recorded in the ECG.

Electrocardiograph (the instrument) is a highly sensitive galvanometer that

measures only the electrical activity of the heart at rest. The conduction of impulses
form the SA node to AV node and then to Purkinje fibres and finally to the ventricular
musculature and the repolarisation generates few mill amperes of electric current. This
is recorded by the instrument and the movement of the galvanometer needle makes
marks on the gridded thermal paper which is called as the electrocardiogram (ECG).
The speed of the rolling paper is usually set at a 25mmper second.

Considering the average heart rate of 72 beats per minute, one cardiac cycle is
considered to be 0.8 seconds approximately. All of us know that, the atrial contraction,
ventricular contraction and relaxation constitute one cardiac cycle. This corresponds to
certain patterns in the ECG.P wave corresponds to the atrial contraction, QRS complex
representing ventricular complex and T wave ventricular repolarisation. (Fig.1)


Usually ECG is recorded in 12 leads. Lead I, II, and III are called as the limb
leads, aVR, aVL, aVF, are called as the augmented limb leads, and V1 to V6 are called
as the chest leads. The normal patterns of ECG representation in different leads vary
greatly. The classic pattern of PQRST wave is usually found in the lead II when the
cardiac axis is at 60degress i.e when it becomes parallel to the orientation of the lead II.
The shift in the cardiac axis will affect the normal patterns being read in all the different
leads. So finding out the orientation of cardiac axis helps us to read ECG efficiently.

Figure 2

ECG reading can be conclusively taken to determine the conduction

abnormalities. Sinus arrhythmias - Tachycardia, Bradycardia, Bundle branch blocks,
Long QT syndrome all belongs to this category. Lead II is usually represented as the
rhythm strip to identify conduction abnormalities more precisely.

Blocks in the coronary arteries never get recorded in the regular ECG in the early
stages. A stress test (Treadmill Test) which records the ECG during activity gives a clue
regarding the decreased blood supply to the heart. This can be confirmed only through
coronary angiogram which is an invasive technique.

The relevance of ECG recording for even mild discomfort increases because of
painless condition of myocardial ischaemia and infarction in diabetics, which can be
assessed only with a ECG. The iso electric line of the ECG has to be noted carefully to
identify signs of Ischaemia and infarction. Any deviation either up or down in the ST
segment is to be considered as a very serious condition. Patterns of ST elevation or
depression (Figure 3,4)
Figure 3,4

The presentation in different leads vary depending on which area of heart is

affected due to atherosclerosis. Changes in lead I, avL , V5, V6 represents lateral side,
Lead II, III and aVF inferior, V1, V2 septal, V4,V5, anterior part.(Figure 5)

Figure 5

It is to be noted that a normal ECG pattern never rules out chances for cardiac
Ischemia or infarction. There are silent areas which do not get reflected in ECG. We
need to rely on the levels of Cardiac enzymes like Troponin and CPK-MB to get the real
evidence to rule out such fatal conditions.
Electrolyte imbalances reflect in the ECG. High and low sodium does not affect
the ECG pattern, but changes in potassium level alter the T waves. Peaked T waves
are seen in Hyperkalemia. (Fig.6)

Figure 6

The skills of ECG interpretation can be perfected only through constant

acquaintance. The interpretation should be attempted methodically in a step wise
manner. Rate, Rhythm, Cardiac Axis, P waves, PR interval, QRS waves, ST-T waves
are to be looked for in an orderly manner and arrive at a probable diagnosis conforming
the clinical history.