Chapter

Electrocardiogram (ECG)
94
„ DEFINITIONS
„ USES OF ECG
„ ELECTROCARDIOGRAPHIC GRID
„ DURATION
„ AMPLITUDE
„ SPEED OF THE PAPER
„ ECG LEADS
„ BIPOLAR LEADS
„ UNIPOLAR LEADS
„ WAVES OF NORMAL ECG
„ ‘P’ WAVE
„ ‘QRS’ COMPLEX
„ ‘T’ WAVE
„ ‘U’ WAVE
„ INTERVALS AND SEGMENTS OF ECG
„ ‘P-R’ INTERVAL
„ ‘Q-T’ INTERVAL
„ ‘S-T’ SEGMENT
„ ‘R-R’ INTERVAL

„ DEFINITIONS Electrocardiogram

Electrocardiography Electrocardiogram (ECG or EKG from electrokardio-

gram in Dutch) is the record or graphical registration
Electrocardiography is the technique by which of electrical activities of the heart, which occur prior to
electrical activities of the heart are studied. The spread the onset of mechanical activities. It is the summed
of excitation through myocardium produces local electrical activity of all cardiac muscle fibers recorded
electrical potential. This low-intensity current flows from surface of the body.
through the body, which acts as a volume conductor.
This current can be picked up from surface of the body
„ USES OF ECG
by using suitable electrodes and recorded in the form
of electrocardiogram. This technique was discovered Electrocardiogram is useful in determining and
by Dutch physiologist, Einthoven Willem, who is diagnosing the following:
considered the father of electrocardiogram (ECG). 1. Heart rate
2. Heart rhythm
Electrocardiograph 3. Abnormal electrical conduction
Electrocardiograph is the instrument (machine) by 4. Poor blood flow to heart muscle (ischemia)
which electrical activities of the heart are recorded. 5. Heart attack
 552 Section 8 t Cardiovascular System

6. Coronary artery disease record electrocardiogram. Heart is presumed to lie in

7. Hypertrophy of heart chambers. the center of Einthoven triangle.
Electrical potential generated from the heart appears
„ ELECTROCARDIOGRAPHIC GRID simultaneously on the roots of the three limbs, namely
the left arm, right arm and the left leg.
The paper that is used for recording ECG is called ECG Refer next Chapter for Einthoven law.
paper. ECG machine amplifies the electrical signals ECG is recorded in 12 leads, which are generally
produced from the heart and records these signals on a classified into two categories.
moving ECG paper. I. Bipolar leads
Electrocardiographic grid refers to the markings II. Unipolar leads.
(lines) on ECG paper. ECG paper has horizontal and
vertical lines at regular intervals of 1 mm. Every 5th line „ BIPOLAR LIMB LEADS
(5 mm) is thickened.
Bipolar limb leads are otherwise known as standard
„ DURATION limb leads. Two limbs are connected to obtain these
leads and both the electrodes are active recording
Time duration of different ECG waves is plotted electrodes, i.e. one electrode is positive and the other
horizontally on X-axis. one is negative (Fig. 94.1).
Standard limb leads are of three types:
On X-axis a. Limb lead I
b. Limb lead II
1 mm = 0.04 second
c. Limb lead III.
5 mm = 0.20 second
Lead I
„ AMPLITUDE
Lead I is obtained by connecting right arm and left arm.
Amplitude of ECG waves is plotted vertically on Y-axis. Right arm is connected to the negative terminal of the
instrument and the left arm is connected to the positive
On Y-axis terminal.
1 mm = 0.1 mV
5 mm = 0.5 mV Lead II
Lead II is obtained by connecting right arm and left leg.
„ SPEED OF THE PAPER Right arm is connected to the negative terminal of the
Movement of paper through the machine can be instrument and the left leg is connected to the positive
adjusted by two speeds, 25 mm/second and 50 mm/ terminal.
second. Usually, speed of the paper during recording
is fixed at 25 mm/second. If heart rate is very high,
speed of the paper is changed to 50 mm/second.

„ ECG LEADS
ECG is recorded by placing series of electrodes on the
surface of the body. These electrodes are called ECG
leads and are connected to the ECG machine.
Electrodes are fixed on the limbs. Usually, right arm,
left arm and left leg are chosen. Heart is said to be in
the center of an imaginary equilateral triangle drawn by
connecting the roots of these three limbs. This triangle
is called Einthoven triangle.

Einthoven Triangle and Einthoven Law

Einthoven triangle is defined as an equilateral triangle FIGURE 94.1: Position of electrodes for standard limb leads
that is used as a model of standard limb leads used to RA = Right arm, LA = Left arm, LL=Left leg.
 Chapter 94 t Electrocardiogram (ECG) 553

Lead III
Lead III is obtained by connecting left arm and left leg.
Left arm is connected to the negative terminal of the
instrument and the left leg is connected to the positive
terminal.

„ UNIPOLAR LEADS
Here, one electrode is active electrode and the other
one is an indifferent electrode. Active electrode is
positive and the indifferent electrode is serving as a
composite negative electrode.
Unipolar leads are of two types:
1. Unipolar limb leads
2. Unipolar chest leads.
FIGURE 94.2: Position of electrodes for chest leads
1. Unipolar Limb Leads (V1 to V6)
Unipolar limb leads are also called augmented limb leads
or augmented voltage leads. Active electrode is connected V3 : In between V2 and V4
to one of the limbs. Indifferent electrode is obtained by V4 : Over left 5th intercostal space on the mid
connecting the other two limbs through a resistance. clavicular line
Unipolar limb leads are of three types: V5 : Over left 5th intercostal space on the anterior
i. aVR lead axillary line
ii. aVL lead V6 : Over left 5th intercostal space on the mid
iii. aVF lead. axillary line.
i. aVR lead
„ WAVES OF NORMAL ECG
Active electrode is from right arm. Indifferent electrode
is obtained by connecting left arm and left leg. Normal ECG consists of waves, complexes, intervals
and segments. Waves of ECG recorded by limb
ii. aVL lead
lead II are considered as the typical waves. Normal
Active electrode is from left arm. Indifferent electrode is electrocardiogram has the following waves, namely P,
obtained by connecting right arm and left leg. Q, R, S and T (Table 94.1 and Fig. 94.3). Einthoven
had named the waves of ECG starting from the middle
iii. aVF lead
of the English alphabets (P) instead of starting from the
Active electrode is from left leg (foot). Indifferent electrode beginning (A).
is obtained by connecting the two upper limbs.
Major Complexes in ECG
2. Unipolar Chest Leads
1. ‘P’ wave, the atrial complex
Chest leads are also called ‘V’ leads or precardial chest 2. ‘QRS’ complex, the initial ventricular complex
leads. Indifferent electrode is obtained by connecting the 3. ‘T’ wave, the final ventricular complex
three limbs, viz. left arm, left leg and right arm, through 4. ‘QRST’, the ventricular complex.
a resistance of 5000 ohms. Active electrode is placed
on six points over the chest (Fig. 94.2). This electrode „ ‘P’ WAVE
is known as the chest electrode and the six points over
‘P’ wave is a positive wave and the first wave in ECG. It
the chest are called V1, V2, V3, V4, V5 and V6. V indicates
is also called atrial complex.
vector, which shows the direction of current flow.
Position of chest leads:
Cause
V1 : Over 4th intercostal space near right sternal
margin ‘P’ wave is produced due to the depolarization of atrial
V2 : Over 4th intercostal space near left sternal musculature. Depolarization spreads from SA node to
margin all parts of atrial musculature. Atrial repolarization is not
 554 Section 8 t Cardiovascular System

TABLE 94.1: Waves of normal ECG

Wave/Segment From – To Cause Duration (second) Amplitude (mV)

P wave – Atrial depolarization 0.1 0.1 to 0.12
Q = 0.1 to 0.2
Onset of Q wave to the Ventricular depolarization and
QRS complex 0.08 to 0.10 R=l
end of S wave atrial repolarization
S = 0.4
T wave – Ventricular repolarization 0.2 0.3
Onset of P wave to onset Atrial depolarization and
P-R interval 0.18 (0.12 to 0.2) –
of Q wave conduction through AV node
Onset of Q wave and Ventricular depolarization and
Q-T interval 0.4 to 0.42 –
end of T wave ventricular repolarization
End of S wave and onset
S-T segment Isoelectric 0.08 –
of T wave

recorded as a separate wave in ECG because it merges „ ‘QRS’ COMPLEX

with ventricular repolarization (QRS complex).
‘QRS’ complex is also called the initial ventricular
complex. ‘Q’ wave is a small negative wave. It is con-
Duration
tinued as the tall ‘R’ wave, which is a positive wave. ‘R’
Normal duration of ‘P’ wave is 0.1 second. wave is followed by a small negative wave, the ‘S’ wave.

Amplitude Cause
Normal amplitude of ‘P’ wave is 0.1 to 0.12 mV. ‘QRS’ complex is due to depolarization of ventricular
musculature. ‘Q’ wave is due to the depolarization of
Morphology basal portion of interventricular septum. ‘R’ wave is due
to the depolarization of apical portion of interventricular
‘P’ wave is normally positive (upright) in leads I, II, septum and apical portion of ventricular muscle. ‘S’
aVF, V4, V5 and V6. It is normally negative (inverted) in wave is due to the depolarization of basal portion of
aVR. It is variable in the remaining leads, i.e. it may be ventricular muscle near the atrioventricular ring.
positive, negative, biphasic or flat (Fig. 94.4).
Duration
Clinical Significance
Normal duration of ‘QRS’ complex is between 0.08 and
Variation in the duration, amplitude and morphology 0.10 second.
of ‘P’ wave helps in the diagnosis of several cardiac
problems such as: Amplitude
1. Right atrial hypertrophy: ‘P’ wave is tall (more than
2.5 mm) in lead II. It is usually pointed Amplitude of ‘Q’ wave = 0.1 to 0.2 mV.
Amplitude of ‘R’ wave = 1 mV.
2. Left atrial dilatation or hypertrophy: It is tall and
Amplitude of ‘S’ wave = 0.4 mV.
broad based or M shaped
3. Atrial extrasystole: Small and shapeless ‘P’ wave, Morphology
followed by a small compensatory pause
4. Hyperkalemia: ‘P’ wave is absent or small ‘Q’ wave is normally small with amplitude of 4 mm or
less. It is less than 25% of amplitude of ‘R’ wave in
5. Atrial fibrillation: ‘P’ wave is absent
leads I, II, aVL, V5 and V6. In the remaining leads, its
6. Middle AV nodal rhythm: ‘P’ wave is absent
amplitude is < 0.2 mm.
7. Sinoatrial block: ‘P’ wave is inverted or absent From chest leads V1 to V6, ‘R’ wave becomes
8. Atrial paroxysmal tachycardia: ‘P’ wave is inverted gradually larger. It is smaller in V6 than V5. ‘S’ wave is
9. Lower AV nodal rhythm: ‘P’ wave appears after QRS large in V1 and larger in V2. It gradually becomes smaller
complex. from V3 to V6.
 Chapter 94 t Electrocardiogram (ECG) 555

FIGURE 94.3: Waves of normal ECG

 556 Section 8 t Cardiovascular System

Clinical Significance
Variation in duration, amplitude and morphology of
‘T’ wave helps in the diagnosis of several cardiac
problems such as:
1. Acute myocardial ischemia: Hyperacute ‘T’ wave
develops. Hyperacute ‘T’ wave refers to a tall and
broad-based ‘T’ wave, with slight asymmetry.
2. Old age, hyperventilation, anxiety, myocardial infarc­
tion, left ventricular hypertrophy and pericarditis: ‘T’
wave is small, flat or inverted
3. Hypokalemia: ‘T’ wave is small, flat or inverted
4. Hyperkalemia: ‘T’ wave is tall and tented.

„ ‘U’ WAVE
‘U’ wave is not always seen. It is also an insignificant
wave in ECG. It is supposed to be due to repolarization
of papillary muscle.

Clinical Significance
Appearance of ‘U’ wave in ECG indicates some clinical
conditions such as:
1. Hypercalcemia, thyrotoxicosis and hypokalemia: ‘U’
wave appears. It is very prominent in hypokalemia.
FIGURE 94.4: 12-lead ECG 2. Myocardial ischemia: Inverted ‘U’ wave appears.
(Courtesy: Dr Atul Ruthra)
„ INTERVALS AND SEGMENTS OF ECG
Clinical Significance
Variation in the duration, amplitude and morphology „ ‘P-R’ INTERVAL
of ‘QRS’ complex helps in the diagnosis of several ‘P-R’ interval is the interval between the onset of ‘P’
cardiac problems such as: wave and onset of ‘Q’ wave.
1. Bundle branch block: QRS is prolonged or deformed ‘P-R’ interval signifies the atrial depolarization and
2. Hyperkalemia: QRS is prolonged. conduction of impulses through AV node. It shows the
duration of conduction of the impulses from the SA node
„ ‘T’ WAVE to ventricles through atrial muscle and AV node.
‘T’ wave is the final ventricular complex and is a positive ‘P’ wave represents the atrial depolarization. Short
wave. isoelectric (zero voltage) period after the end of ‘P’
wave represents the time taken for the passage of
Cause depolarization within AV node.
‘T’ wave is due to the repolarization of ventricular Duration
musculature.
Normal duration of ‘P-R interval’ is 0.18 second and
Duration varies between 0.12 and 0.2 second. If it is more than
0.2 second, it signifies the delay in the conduction of
Normal duration of ‘T’ wave is 0.2 second. impulse from SA node to the ventricles. Usually, the
delay occurs in the AV node. So it is called the AV nodal
Amplitude delay.
Normal amplitude of ‘T’ wave is 0.3 mV.
Clinical Significance
Morphology
Variation in the duration of ‘P-R’ intervals helps in the
‘T’ wave is normally positive in leads I, II and V5 and V6. diagnosis of several cardiac problems such as:
It is normally inverted in lead aVR. It is variable in the 1. It is prolonged in bradycardia and first degree heart
other leads, i.e. it is positive, negative or flat. block
 Chapter 94 t Electrocardiogram (ECG) 557

2. It is shortened in tachycardia, Wolf-Parkinson- 3. ‘S-T’ segment is prolonged in hypocalcemia

White syndrome, Lown-Ganong-Levine syndrome, 4. ‘S-T’ segment is shortened in hypercalcemia.
Duchenne muscular dystrophy and type II glycogen
storage disease. „ ‘R-R’ INTERVAL
‘R-R’ interval is the time interval between two consecutive
„ ‘Q-T’ INTERVAL
‘R’ waves.
‘Q-T’ interval is the interval between the onset of ‘Q’
wave and the end of ‘T’ wave. Significance
‘Q-T’ interval indicates the ventricular depolarization ‘R-R’ interval signifies the duration of one cardiac
and ventricular repolarization, i.e. it signifies the cycle.
electrical activity in ventricles.
Duration
Duration
Normal duration of ‘R-R’ interval is 0.8 second.
Normal duration of Q-T interval is between 0.4 and 0.42
second. Significance of Measuring ‘R-R’ Interval

Clinical Significance Measurement of ‘R-R’ interval helps to calculate:

1. Heart rate
1. ‘Q-T’ interval is prolonged in long ‘Q-T’ syndrome, 2. Heart rate variability.
myocardial infarction, myocarditis, hypocalcemia
and hypothyroidism 1. Heart Rate
2. ‘Q-T’ interval is shortened in short ‘Q-T’ syndrome
and hypercalcemia. Heart rate is calculated by measuring the number of ‘R’
waves per unit time.
„ ‘S-T’ SEGMENT Calculation of heart rate
‘S-T’ segment is the time interval between the end of Time is plotted horizontally (X-axis). On X-axis, interval
‘S’ wave and the onset of ‘T’ wave. It is an isoelectric between two thick lines is 0.2 sec (see above). Time
period. duration for 30 thick lines is 6 seconds. Number of ‘R’
waves (QRS complexes) in 6 seconds (30 thick lines)
J Point is counted and multiplied by 10 to obtain heart rate. For
the sake of convenience, the ECG paper has special
The point where ‘S-T’ segment starts is called ‘J’ point. time marking at every 3 seconds. So it is easy to find the
It is the junction between the QRS complex and ‘S-T’ time duration of 6 seconds.
segment.
2. Heart Rate Variability
Duration of ‘S-T’ Segment
Heart rate variability (HRV) refers to the beat-to-
Normal duration of ‘S-T’ segment is 0.08 second. beat variations. Under resting conditions, the ECG of
healthy individuals exhibits some periodic variation in
Clinical Significance ‘R-R’ intervals. This rhythmic phenomenon is known as
Variation in the duration of ‘S-T’ segment and its respiratory sinus arrhythmia (RSA), since it fluctuates
deviation from isoelectric base indicates the patholo- with the phases of respiration. ‘R-R’ interval decreases
gical conditions such as: during inspiration and increases during expiration
(Chapter 96).
1. Elevation of ‘S-T’ segment occurs in anterior or
inferior myocardial infarction, left bundle branch
Significance of Heart Rate Variability
block and acute pericarditis. In athletes, ‘S-T’
segment is usually elevated HRV decreases in many clinical conditions like:
2. Depression of ‘S-T’ segment occurs in acute myo- 1. Cardiovascular dysfunctions such as hypertension
cardial ischemia, posterior myocardial infarction, 2. Diabetes mellitus
ventricular hypertrophy and hypokalemia 3. Psychiatric problems such as panic and anxiety.