Electrical Activity of

the Heart
By dr shazia askari
 ECG(electrocardiograph)

• ECG is define as ‘’ recording of electrical activity of

heart on a graph paper.’’
Or
• Graphical representation of electrical activity of
heart.
 Electrocardiograph.

• The machine which is used to record the electrical

activity of heart is ELECTROCARDIOGRAPH.
• a) ECG machine.
• b) power lab.
 Electrocardiogram.

• The graph on which this electrical activity is recorded

is called ELECTROCARDIOGRAM.
 Significance of ECG.

• ECG gives information about rate and rhythm of

the heart.
• The physical orientation of heart i.e axis.
• Its a diagnostic tool for various heart conditions like
hypertrophies , ischemia, infarction , arrhythmias
conduction problems and pace maker activity.
• ECG does not provide information about
mechanical activity.
 ECG paper.

• This is long role of paper ,composed of small

squares .
• One square is 1mm wide and 1 mm high.
• On ECG paper there are thick lines, between two
thick lines there are 5 small squares.
• The speed of ECG machine is 25 mm per second.
ECG paper.
 ECG Paper.

• The time internal of each small square can be

calculated as
• 25 small sqrs are equal to 1 second.
• 1 small sqr is equal to 1/25 second.
• i.e 0.04 seconds.
 ECG paper

• vertically the small square represent the amount of

electrical potential.
• One small sqr represent the potential of 0.1 mv.
• 10 small squares represent the potential of 1 mv.
 ECG leads.

• leads are electrodes which record the

electrical potential of heart at different sites.
• There are 12 ECG leads.
a) 3 bipolar limb leads.
b) 3 augmented limb leads.(unipolar).
c) 6 chest leads.
 Bipolar limb leads.

• Lead 1 = left arm + ve , right arm _

ve
• Lead 2 = right arm _ ve ,left leg + ve..
• Lead 3 = left arm _ ve , left leg +ve.
 Augmented limb leads.

• AVR attach to right arm..

• AVL attach to left arm.
• AVF attach to left foot.
 Einthoven”s triangle

• Einthoven s triangle is a diagrammatic

way of illustrating that the two arms
and left leg form the apices of triangle
surrounding the heart.
• It is an equilateral triangle.
 Einthoven “s rule.

• Einthovens law states that if the

electrical potentials of two leads are
known at any instant ,the third can be
determine by simply summing the first
two.
Waveforms in ECG
Lecture no 2
 Always remember.

• Positive electrode is always a reference electrode.

• Depolarization wave moves toward the positive
electrode gives positive deflection.
• Depolarization wave move away from positive
electrode gives the negative deflection.
 Wave forms.

 P wave
 Atrial depolarization
 QRS complex
 Ventricular depolarization
 T wave
 Ventricular repolarization
 Basic terminologies

 Base line : flat, straight and isoelectric line

 Wave form :deviation or movement away
from base line may be upward or downward
 Segment : A line between two waves
 Interval : a wave form plus a segment this
shows time duration
 Complex : combination of several wave form
without segment.
 P wave

• P Wave shows atrial depolarization..

• Its duration is 0.1 sec (2 and half small sqr) and
height is 2.5 mv (2 and half small sqr).
• Presence of p waves in ECG strip shows the sinus
rhythm.
 Abnormalities of P wave.

 P .pulmonale :- This is tall and peaked P wave in

lead 1 and lead 2 and 3 in right atrial hypertrophy.
(pulmonary hypertension).
 P. mitrale ;_ It is biphasic or broad P wave seen in
left atrial hypertrophy.(mitral stenosis).
-. Best seen in lead 2.
 P wave.

• Inverted P wave :- may be present in .

• a) Normally in lead V 1 and V2..
• b) In dextro cardia.
• c) Incorrectly placed electrodes.
 QRS complex.

• QRS complex represent the ventricular

depolarization.
• its normal duration is about 0. 08 seconds.( less than
2 small sqr) and hight is about 5 to 20 small sqrs.
• It is a wide complex because it mask the atrial
repolarization.
• Q wave is first wave of this complex but often
absent.
 QRS complex.

• Q wave present the interventricular septal

depolarization.
• It is first wave in ECG with negative deflection.

• Q wave greater than 1/3 the height of the R wave,

greater than 0.04 sec are abnormal and may represent
the old infarction.
.
 Low voltage QRS complex.

• when the height of R or S wave is not more than

5mm… it is seen in..
Hypothyroidism.
Pericardial effusion.
Thick chest wall.
Problem in ECG machine.
 High voltage QRS complex.

• This is present in ventricular hypertrophies.

• The maximum voltage of QRS complex may be 35
mv(35 small square).
• V1 and V2 show high voltage QRS complex in right
ventricular hypertrophy.( s wave)
• V5 and V6 show such QRS complex in left
ventricular hypertrophy. (r wave)
 T Wave.

• it represent the ventricular repolarization.

• It is repolarizing wave but shows the upward

deflection because the part depolarized in the last is
first to be repolarized,, that is base of heart
depolarized in the last but is first to be repolarized.
 T wave.

•
• T wave should not be more than one third of R
wave.
• T wave inversion represent ischemia of heart.
• Tall and peaked R wave is present in hyperkalemia.
• Flattened R waves in pericarditis and myocarditis.
 PR interval.

• This is from beginning of P wave to the beginning

of Q wave.
• Its normal duration is from 0.12 to 0.2 sec..
• It represent the conduction time of impulse from SA
node to the ventricles and AV delay.
 Prolong PR interval.

• Prolong PR interval shows delayed conduction from

SA to AV node….
 In first degree heart , 2nd degree and complete heart
block.
Digitalis therapy.
 Hyperkalemia.
 First degree heart block.

• A-V BLOCK, FIRST DEGREE

Atrio-ventricular conduction lengthened
• Interval is about 0.2 to 0.3 sec.
 Second degree heart block.

• A-V BLOCK, SECOND DEGREE

Sudden dropped QRS-complex
• PR interval is about 0.4 sec.
•
3rd degree heart block
 3rd degree heart block.

• When there is AV block , atria continue to beat at

normal rhythem while new pace maker develops in
purkinjie system with a rate of 15 to 50 beats /min.
• With a sudden block purkinje system cannot take
over pace maker activity immediately ,it takes about
16 to 30 sec. during which ventricles fail to contract
and person faint.
• This delayed pickup of heart beat is called stokes
Adams syndrome.
 QT interval

• Measured from beginning of Q to the

end of the T wave
. Its duration is about (10 small sqrs).
. it indicates total systolic time of ventricles.
RR interval.
 ST segment.

• this segment present between S wave and T

wave.
• It represent the plateau phase.
• its duration is 0.04 sec .
 J point.

• The exact point at which all parts of ventricles are

depolarized i.e at the just end of QRS comples and
just at the begining of ST segment.
• At the point potential of ECG is zero with no
current is flowing through heart.
 ST segment

• Elevation . Seen in recent MI and

hyperkalemia.
• Depression. Seen in ischemia, digitalis
therapy and hypokalemia.
Lecture 3
ECG
 Electrophysiology

 If an electrode is placed so that wave of

depolarization spreads toward the recording
electrode, the ECG records a positive
(upward) deflection.
 If wave of depolarization spreads away from
recording electrode, a negative (downward)
deflection
Waves in limb leads.
Waves in augmented limb leads
1. ECG recording of electrical activity not the
mechanical function
2. ECG is not a direct depiction of abnormalities
3. ECG does not record all the heart’s electrical
activity
Lecture 4
ECG helps to know?
 How to calculate heart rate.

heart rate define as the no of heart beats per

minute.it can be determine by ECG VIA TWO
RULES.

 Rule of 300

 10 Second Rule
 Rule of 300

Take the number of “big boxes” between

neighboring QRS complexes, and divide this
into 300. The result will be approximately
equal to the rate.

Although fast, this method only works for

regular rhythms.
What is heart rate???????
Heart rate?
Heart rate ?
 Rule of 10 sec

As most EKGs record 10 seconds of rhythm per

page, one can simply count the number of
beats present on the EKG and multiply by 6 to
get the number of beats per 60 seconds.

This method works well for irregular rhythms

 Rhythm.

• This is checked by the intervals between two R

waves or two S waves.
• If the no of small or large sqs are equal between two
R or S waves,, the rhythm is said to be normal.
• If not the rhythm is said to be irregular.
• Irregular rhythm is called Arrythmias.
Normal sinus rhythm
 Sinus arrhythmia

• There is sinus rhythm , but the RR interval

(heart rate) varies with respiration.
• Heart rate increase during inspiration and
decrease during expiration.
Cardiac Rhythm:
Supraventricular
 Atrial flutter.

• When atrial rate is between 200 to 300 betas /min

• During atrial flutter AV node is not able to transmit
all the impulses to ventricles so ventricular rate is 1/3
or ¼ of atrial rate.
• P wave is like saw tooth.
• Present is IHD , rheumatic heart disease.
 ATRIAL FLUTTER

Impulses travel in regular and circular course in

atria – No interval between T and P.
 Atrial fibrillation.

• A totally irregular and rapid atrial rate in which there

is a contraction of only small portion of atrial
musculature.
• P waves replace by irregular F waves , bcoz whole
atria is not contracting.
• QRS complex and T waves r normal but rhythm is
irregular.
ATRIAL
FIBRILLATION

Impulses have random pathways in atria.

 VENTRICULAR
TACHYCARDIA
•
Impulse originate at ventricular pacemaker –
odd/wide QRS complex - often due to
myocardial infarction , rate is about 120/ to
220/ min.
 Ventricular fibrillation.

• Rapid ,irregular and ineffective contractions

of small segments of ventricles is termed as
ventricular fibrillation.
• Peripheral pulse is absent bcoz cardiac out
put is zero.
VENTRICULAR FIBRILLATION

hapazerd ventricular depolarization – ineffective at

pumping – death within minutes
•
•
 Cardiac axis

• The flow of current from one point to another is

representing by an arrow. This is called Vector.
• The direction of flow of current i.e the arrow
point is always towards the positive direction.
The range of cardiac axis is 0 to +90 degrees.
Beyond this limit it is said to be deviated.
Vector Analysis
 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)
 Axis deviation

• Deviation to R: increased activity in R vent. –

obstruction in lung, pulmonary emboli, some heart
disease
• Deviation to L: increased activity in L vent. –
hypertension, aortic stenosis, ischemic heart disease
The quadrant approach
RAD Negative in I, positive in
AVF