Basics of Electrocardiography

What is an ECG?
An ECG is the recording (gram) of the electrical activity(electro) generated by the cells of the heart(cardio) that reaches the body surface.

Recording ECG
William Einthoven

Useful in diagnosis of
Cardiac Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances Drug effects and toxicity

Recording an ECG

Basics
ECG graphs: 1 mm squares 5 mm squares Paper Speed: 25 mm/sec standard Voltage Calibration: 10 mm/mV standard

ECG Paper: Dimensions

5 mm 1 mm

Voltage ~Mass
0.1 mV

0.04 sec 0.2 sec

Speed = rate

ECG Leads
The standard ECG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads 6 Precordial Leads

The axis of a particular lead represents the viewpoint from which it looks at the heart.

Summary of Leads
Limb Leads
Bipolar Unipolar I, II, III
(standard limb leads)

Precordial Leads
V1-V6

aVR, aVL, aVF

(augmented limb leads)

Anatomic Groups
(Summary)

Interpretation of an ECG

Steps involved
Heart Rate Rhythm Axis Wave morphology Intervals and segments analysis Chamber enlargement Specific changes

Wave forms

Cardiac Conduction: Cycle Initiation

Cardiac Conduction: P Wave

Cardiac Conduction: AV Node

Cardiac Conduction: Bundle Branches

Cardiac Conduction: Purkinje Fibers

Cardiac Conduction: QRS Complex

Cardiac Conduction: Plateau Phase

Cardiac Conduction: T-Wave

Label the ECG

P Wave: Atrial Depolarization.
Can be positive, biphasic, negative.

QRS Complex: Ventricular Depolarization.

Q Wave: 1st negative deflection wave before R-Wave.

R Wave: The positive deflection wave.

S Wave: 1st negative deflection wave after R wave.

T Wave:

Ventricular Repolarization.

Can be positive, biphasic, negative.

Calculating Heart Rate

1) Measure Cycle Length (CL).
1) (# small boxes from R R) (40ms) = CL .

2) Calculate HR
60,000/CL = x BPM
(20)(40ms) = 800ms 60,000/800 = 75 bpm

(25)(40ms) = 1000ms 60,000/1000 = 60 bpm

(12)(40ms) = 480ms 60,000/480 = 125 bpm

Calculating the Heart Rate The Rule of 300

# of big boxes 1 2 3 Rate 300 150 100

4 5 6

75 60 50

The QRS Axis

The QRS axis represents the net overall direction of the hearts 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 Positive

Predominantly Negative

Equiphasic

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.

Example 1

Negative in I, positive in aVF RAD

Example 2

Positive in I, negative in aVF

Predominantly positive in II

Normal Axis (non-pathologic LAD)

Marked RAD

-90 -120 aVR -150

-60
LAD

-30 aVL 0 I

180

150 30 120 III 60 90 aVF II

Normal Axis -30 to +100

RAD

Example 1

Equiphasic in aVF Predominantly positive in I QRS axis 0

Example 2

Equiphasic in II Predominantly negative in aVL QRS axis +150

Common causes of LAD

May be normal in the elderly and very obese Due to high diaphragm during pregnancy, ascites, or ABD tumors Inferior wall MI Left Anterior Hemiblock Left Bundle Branch Block WPW Syndrome Congenital Lesions RV Pacer or RV ectopic rhythms Emphysema

Common causes of RAD

Normal variant Right Ventricular Hypertrophy Anterior MI Right Bundle Branch Block Left Posterior Hemiblock Left Ventricular ectopic rhythms or pacing WPW Syndrome

The Normal ECG

Normal Sinus Rhythm

Originates in the sinus node Rate between 60 and 100 beats per min P wave axis of +45 to +65 degrees, ie. Tallest p waves in Lead II Monomorphic P waves Normal PR interval of 120 to 200 msec Normal relationship between P and QRS Some sinus arrhythmia is normal

Sinus Arrhythmia

ECG Characteristics:

Presence of sinus P waves

Variation of the PP interval which cannot be attributed to either SA nodal block or PACs

When the variations in PP interval occur in phase with respiration, this is considered to be a normal variant. When they are unrelated to respiration, they may be caused by the same etiologies leading to sinus bradycardia.

Normal P wave
Atrial depolarisation Duration 80 to 100 msec Maximum amplitude 2.5 mm Axis +45 to +65 Biphasic in lead V1 Terminal deflection should not exceed 1 mm in depth and 0.03 sec in duration

Normal P wave

PR interval
AV node conduction From the beginning of P wave to the beginning of q wave 120-200 ms

Normal QRS complex

Completely negative in lead aVR , maximum positivity in lead II rS in right oriented leads and qR in left oriented leads (septal vector) Transition zone commonly in V3-V4 RV5 > RV6 normally Normal duration 50-110 msec, not more than 120 msec Physiological q wave not > 0.03 sec

ECG showing qR pattern in lead III ,disappears on deep inspiration q wave not significant Mech:shift in the QRS axis

QRS-T angle
The normal t wave axis is similar to the QRS axis Normally the QRS-T angle does not exceed 60 deg

Amplitude of QRS
Depends on the following factors 1.electrical force generated by the ventricular myocardium 2.distance of the sensing electrode from the ventricles 3.Body build;a thin individual has larger complexes when compared to obese individuals 4.direction of the frontal QRS axis

Normal T wave
Same direction as the preceding QRS complex Blunt apex with asymmetric limbs Height < 5mm in limb leads and <10 mm in precordial leads Smooth contours May be tall in athletes

ST segment
Merges smoothly with the proximal limb of the T wave No true horizontality

Normal u wave
Best seen in midprecordial leads Height < 10% of preceding T wave Isoelectric in lead aVL (useful to measure QTc) Rarely exceeds 1 mm in amplitude May be tall in athletes (2mm)

QT interval
Normally corrected for heart rate Bazetts formula Normal 350 to 430 msec With a normal heart rate (60 to 100), the QT interval should not exceed half of the R-R interval roughly

Measurement of QT interval
The beginning of the QRS complex is best determined in a lead with an initial q wave leads I,II, avL ,V5 or V6 QT interval shortens with tachycardia and lengthens with bradycardia

Prolonged QTc
During sleep Hypocalcemia Ac myocarditis AMI Drugs like quinidine,procainamide,tricyclic antidepressants Hypothermia HOCM

Advanced AV block or high degree AV block Jervell-Lange Neilson syndrome Romano-ward syndrome

Shortened QT
Digitalis effect Hypercalcemia Hyperthermia Vagal stimulation

Normal Variants in the ECG

Sinus arrhythmia Persistent juvenile pattern Early repolarisation syndrome Non specific T wave changes

Persistent juvenile pattern

Features of ERPS
Vagotonia / athletes heart Prominent J point Concave upwards, minimally elevated ST segments Tall symmetrical T waves Prominent q waves in left leads Tall R waves in left oriented leads Prominent u waves Rapid precordial transition Sinus bradycardia

Early Recognition Prevents Streptokinase infusion !

Reporting an ECG

1. Patient Details
Whose ECG is it ?!

2. Standardisation and lead placement

Is it properly taken ?

3. Analysis of Rate, Rhythm and Axis

4. Segment and wave form analysis

Final Impression
Does the ECG correlate with the clinical scenario ?

Thank you !