THE PHYSIOLOGICAL

BASIS OF THE EKG

Dr. Guido E. Santacana
Professor
Dept. of Physiology

After this section you should be able to:

Differentiate between an intracellular action potential and the electrocardiogram

as an extracellular recording.
Recognize the concept of the dipole and electrical potential vector and how it
applies to the heart and EKG recording.
Recognize that the cumulative electrical activity of the heart forms dipoles or
electrical potential vectors in different directions as the activation of the heart
progresses.
Recognize that the multiple dipoles or electrical potential vectors generated by
the heart produce the EKG recording.
Learn the 12 EKG Leads and their projection of the lead vectors in three
orthogonal planes.
Understand how each EKG wave is generated using Lead I as an example.
Perform a simple sequential analysis of the EKG.
Learn the standards of the EKG recording paper.
Understand the origin of the Mean QRS Axis concept.
Using the Electrical Axis Circle of the heart learn to estimate Mean Electrical
Axis.
Calculate the Mean QRS Axis by vector analysis using three or two standard
leads.
Recognize the effect of left or right hypertrophy on the Mean QRS Axis.
Recognize the effect of left or right Bundle Branch Block on the Mean Electrical
Axis.
Understand the concept of current of injury and its clinical implications.
Learn to estimate the site of an ischemic injury using the concept of the J Point.

The Conduction System of the

Heart

Action Potentials = Change in membrane

potential occurring in nerve, muscle, heart and
other cells

The ECG is not an action potential but

reflects their cumulative effect at the
level of the skin where the recording
electrodes are located.

THE DIPOLE CONCEPT

METER
C

+2

JAR

-2

B -

+ A

POS
NEG

BATTERY

EINTHOVENS TRIANGLE
AND LIMB LEADS
B
B

Einthovens Original EKG Recorder

String Galvanometer Based

EKG Recorder. Patient with
hands submerged in strong
salt solution.

String Galvanometer
Schematic.

What are we looking at in the EKG

waves?

VOLTAGE!!
As amplitude in
Millivolts.
Baseline at 0mv
TIME!!
Duration in fractions of a second

Atrial Depolarization
P wave (Lead I)

Zero
potential

P
+

+
0
-

Peak
Potential

Ventricular Conducting System

AV Node
Bundle of His

Left Bundle Branch

Right Bundle
Branch

Left Posterior Fascicle

Septal fascicle
P
Left Anterior
Fascicle

P= Purkinje Fibers

Ventricular Septal
Depolarization- the Q Wave

0
Q

Ventricular Depolarization-the R Wave

3
4

+
0

Ventricular Depolarization-The S Wave

B.

A
B.

+
+

QRS Configurations

RSR

QRS

RS

QR

QS

Ventricular Repolarization- the T Wave

+
B

+
0

Review of the Sequence in the

Formation of the EKG

Intervals and Segments of the

Normal EKG

INTERVALS AND SEGMENTS !

PR Interval- Onset of P wave to
onset of QRS. (.12-.20sec or 35 small squares)
QRS Interval-Beginning and end
of QRS wave.(<.12sec duration
or 3 small squares)
QT interval- Beginning of QRS
to end of T wave.( Calculated as
corrected QT = .42 sec)
ST segment ( no elevation or
depression)

A
0

Limb Leads=Frontal Plane

B
60
A

+A

-150
B -

-B

B
120
A
B 90

-30
A

Chest Leads = Horizontal Plane

B

The Chest or Precordial Leads

V6

V5

V1

V2

Over right
ventricle

V3

Over the
Left Ventricle

V4

Over Interventricular
Septum

Projection of the 12 Lead EKG Vectors

in Three Orthogonal Planes

Review of what each EKG Lead

looks at.
Y

Z
X

Anterior Leads
V1,V2,V3,V4
Inferior Leads
II,III,AVF

Left lateral
Leads
I, AVL,V5
V6

MEAN QRS AXIS BASICS

WHAT IS THE MEAN QRS AXIS?
IT REPRESENTS THE AVERAGE DIRECTION OF THE
INSTANTANEOUS FORCES GENERATED DURING
THE SEQUENCE OF VENTRICULAR DEPOLARIZATION.

NORMAL RANGE= -30 TO +90 DEGREES

NORMAL VALUE= 59 DEGREES
MORE - THAN -30 = LEFT AXIS DEVIATION
MORE + THAN +90 = RIGHT AXIS DEVIATION

Instantaneous and Mean Vectors of

Ventricular Depolarization
-90

180

G
F
E
A B
C D Mean Vector

+90

The Electrical Axis Circle

Where does it come from?
Lead I

Lead I 0
Lead
II
Lead III

Lead III

Lead
120
II
REMEMBER EINTHOVEN
60

The three Leads with a Common

Center

Lead I 0

Lead III
120

Lead
II
60

THE ELECTRICAL AXIS CIRCLE!

-120

-90
-60

aVR- -150

aVL - -30

+180

I- 0

Normal
+150

Range

III- +120

+30
II - +60

aVF- + 90

Using the Circle to Estimate MEA

TO ESTIMATE QRS AXIS

-90

Lead II QRS UP
-30

I-0

+180
Lead I
QRS UP

+150

II - +60

+90
-30

NORMAL AXIS

The Isoelectric QRS and its use!

aVL
-30

+60
Lead perpendicular to the
isoelectric QRS

II

Why is a Wave Biphasic?

Cardiac Muscle

-----------------++++++++++
Lead

Meter

Cardiac Muscle
++++ ---------------- +++++
Lead

Meter

Cardiac Muscle
---------+++++

++++
------Lead

Meter

Electrode Perpendicular to Direction of Depolarization

Why is Lead aVL Biphasic?

+
Lead aVL

LA
RA

M
ea
n

QR
S
RV

LV

Lead I
+

+
Lead II

Quick Estimation of Axis Deviation

I

I
AVF

Extreme
Right axis
deviation

AVF
Left axis
deviation

0 Lead I
Right axis
deviation.

Normal axis

I
AVF

AVF
+90 Lead AVF

Ventricular Hypertrophy 1

Limb Leads

Precordial Leads

Ventricular Hypertrophy 2
Precordials
S wave

R exceeding 18mm
R exceeding 26mm

Review of Vectors and

Vectorial Analysis of the
EKG
Guido E. Santacana Ph.D.
Professor
Department of Physiology

Basis for Vectorial Analysis

The Boat example!!!
Actual Direction
(Resultant Vector)
Graphical Representation
y

Wind 10 knots

20 knots

Vectorial Analysis of the Mean

Electrical Axis

EKG (LEAD I): Projected Vectors for

different Mean Electrical Axes
Tilted Mean Vectors
Partial Voltage Reading

Parallel Mean Vectors

LEAD I

Higher Voltage Reading

Perpendicular
Mean Vectors
-

No Voltage Reading

LEAD I

NO PROJECTED VECTOR!!!!!

LEAD I

The Concept of the Projected

Vector
A=Mean Vector
B=Projected Vector
Figure A

Figure B

Projected Vectors for theThree

Standard Leads

Ventricular Depolarization Analysis

Using the Projected Vectors
.01 sec

.02 sec

.05 sec
.035 sec

.06 sec

Ventricular Repolarization Analysis

Using the Projected Vectors

What is the Vectorcardiogram?

It is simply the path marked by the positive ends of

The depolarization vectors.

How to Plot the Mean Electrical

Axis Using Two EKG Leads
R wave only = 6mm
or .6mv

6mm
6mm

Mean Electrical Axis

RS waves
R= 8mm
S= -2mm
Total = 8-2=6mm
or .6mv

Abnormal Ventricular Conditions

That Cause Axis Deviation
Change in position of the heart in the
chest.
Hypertrophy of one ventricle.
Bundle Branch Block.

Vectorial Analysis of Ventricular

Hypertrophy

-15

Left ventricular hypertrophy in a hypertensive heart.

Reasons for deviation are LV mass and conduction time.

Vectorial Analysis of Right

Ventricular Hypertrophy
Notice also the
High voltage
EKG in Lead I

170
170

RV Hypertrophy caused by Pulmonary Valve Stenosis

Vectorial Analysis in Bundle Branch

Block
Prolongued
QRS due to
Slower
Conduction
Time Through
Block

-50 left deviation

Left axis deviation caused by a Left Bundle Branch Block

Vectorial Analysis in Bundle Branch

Block

Right Bundle Branch Block producing a right axis deviation.

Again observe the longer QRS interval. Longer QRS intervals
Can distinguish axis deviations due to BBBs vs. hypertrophies.

Low Voltage EKG

Normal voltage
between R wave
and S wave should
be from .5 to 2mv
If the sum of the
voltages in the QRS
of leads I,II,III is
greater than 4mv
the EKG is considered
as high voltage.

Low voltage EKG due to myocardial infarction.

Low voltage EKG is also caused by pericardial effusion, pleural effusion
and pulmonary emphysema.

The Current of Injury

Cardiac abnormalities specially those
that damage the heart muscle cause
part of the heart to remain partially
or totally depolarized all the time.
The current that flows even between
heartbeats from the pathologically
depolarized area to the normal area
is the CURRENT OF INJURY.

Causes of the Current of Injury

Mechanical Trauma.
Infections
Ischemia caused by coronary
occlusions. (Most common cause)

The Current of Injury

Current
of injury
remains after
the heart has
Repolarized.

EKG Generation in Normal vs.

Infarcted Heart

NORMAL

INFARCTED

The J Point and the Current of

Injury Vector Analysis
J Point is the
zero potential
line from which
the direction
of the injury
current is determined

Injury Potential in Anterior Wall

Infarction
Respective J Points
In Leads I and III

J point in V2
an anterior
Lead

Injury Potential in Posterior Wall

Apical Infarction
J Points of
Leads II &
III.
J point of
V2

Cardiac Arrhythmias
Result from disturbances of

IMPULSE
PROPAGATION

IMPULSE
INITIATION

Conduction Blocks
Reentry rhythms

SA Node
Ectopic Foci

Alteration of SA Rhythm
Autonomic nervous system usually
involved.
P, QRS, T waves normal.
Duration of Cardiac Cycle P-P interval
shortened or prolonged.
Sinus Bradycardia- Slow Rhythm.
Sinus Tachycardia- Fast Rhythm.
Cardiac frequency changes gradually.

Bradycardia
Normal Rhythm

Bradycardia

bradycardia occurs when the hearts rate is

slower than 60 beats per minute.

Tachycardia
Normal Rhythm

Tachycardia

Sinus tachycardia occurs when the sinus rhythm

is faster than 100 beats per minute

AV Transmission Blocks
Impulse transmission through
conduction tissue blocked.
His Bundle Electrogram may be used
to localize block.

His Bundle Electrogram

Prolongation of either
the A-H or H-V interval
indicates block above or
below the Bundle of His

Atrial Wave

His Bundle
Wave

V
Ventricular wave

Paroxysmal Tachycardia
Abrupt onset and termination.
Origin is ectopic site.
Reentry circus movements most
frequent cause.
High frequency.
Can cause lightheadedness or
syncope.
Rapid contractions reduce ventricular
filling.

Paroxysmal Supraventricular
Tachycardia

Originate in atria or AV tissue.

Usually from a reentry loop in atrial, AV tissue or both.

Paroxysmal Ventricular Tachycardia

From ectopic foci in the ventricles.

From considerable ischemic damage.
Bizarre QRS complexes
May be a precursor of Ventricular Fibrillation
Results from digitalis toxicity.

Fibrillation
Arrhythmia that is ineffectual in
pumping blood.
Atria or Ventricles may be involved.
Is due to fragmentation of reentry
loop into multiple irregular circuits.

Atrial Fibrillation

Atria do not contract and relax sequentially.

No contribution to ventricular filling.
No P waves. Irregular fluctuations or f waves.
Normal QRS complexes but irregular rhythm.
Compatible with life and full physical activity.
20-30% reduction in ventricular pumping.

Ventricular Fibrillation

Irregular continuous twitching of the ventricular muscle.

No pumping of blood possible.
Loss of conciousness occurs rapidly
Irregular fluctuations in the EKG
Often initiated by a premature impulse arriving in the
vulnerable phase.
Vulnerable phase coincides with downslope of the
T wave.
Electric shock used to treat VF by leaving the
ventricles temporarily refractory and allowing
the SA node to take over again.

Mechanism of Ventricular
Fibrillation

Causes of reentry
Circus movements

Long Pathway= dilated hearts

Decreased velocity of conduction=blockade of Purkinje System
Greatly shortened refractory period= Epinephrine

60 Hz AC Induced VF
60Hz 120VAC
Applied here

End result

Atrial Flutter
F wave

Normal EKG

Wolf Parkinson-White Syndrome

Normal

Wolf Parkinson White

Alternate Conduction Pathway

Bundle of Kent

SEQUENTIAL APPROACH TO
THE EKG
Gain familiarity with the normal EKG.
Evaluate the rhythm.
Calculate rate.
Evaluate each P wave, QRS, ST segment
and T wave in each lead.
Mean QRS Axis
Abnormalities of the P wave
Abnormalities of the QRS
ST and T wave abnormalities.

The Normal EKG - 12 lead

Reading the EKG Paper

BASICS

Each individual
horizontal and vertical
line is ruled in 1 mm
Each horizontal space
represent a time
interval of 0.04 sec
Each vertical space
represents a voltage
change of 0.1 mv

0.5
mv

0.2 sec.

HEART RHYTHM
Every P wave followed by a QRS.
Every QRS preceded by a P wave
P wave upright in leads I, II, III
PR interval greater than .12 sec
P wave rate 60-100BPM with < 10%
variation. < 60 - sinus bradycardia,
>100sinus tachycardia. Variation of
more than 10% = Sinus arrhythmia

CALCULATE HEART RATE

STANDARD EKG PAPER SPEED OF 25MM SEC

HEART RATE = 25MM SEC X 60SEC/MIN

MM/BEAT
OR!!

= 1500
# of small boxes between 2 beats

Example
23

There are 23 mm between the

two QRS complexes, therefore:
Heart rate = 1500/23 = 65
beats/min

Analyzing The Normal EKG

Left Atrial Enlargement

Right Atrial Enlargement

Sample Abnormality of the

P wave
MITRAL
STENOSIS

P waves not visible

random rhythm
right ventricular hypertrophy
atrial fibrillation

AV BLOCK

Exercise Intolerance

Ventricular Escape Rythm

Hyperkalemia

Small or absent P waves

Atrial Fibrillation
Wide QRS
Shortened or absent ST segment
Wide and tall T waves
Ventricular fibrillation (sometimes)

Haemodialysis

Hypokalemia

Small or absent T waves

1st or 2nd degree heart AV block
slight depression of ST segment

Vomiting (prolonged)