ECG

ECG
• Electrocardiography -- recording of the electrical activities of heart.
• Electrocardiograph – instrument
• Electrocardiogram – record obtained.

• Conducting system of heart

• SA node -- AV node - internodal tracts 
Bundle of His with Rt & Lt branches - purkinje fibres

William Einthovan ---- Father of modern ECG

• Body acts as a volume conductor
• Body fluids –good conductors of electrolytes
( it contains ions & electrolytes )

• During generation of cardiac impulse in SAN,

electrical currents are produced in the heart.

• Electric currents spread through conducting system, working myocardial

fibres and spread through entire body and also reach on body surface

• From body surface these electrical events can be picked up by placing

suitable electrodes
• ECG --- A record of the sum total of the electrical events in the heart
during cardiac cycle obtained from the body surface

• Sir William Einthoven --- father of modern ECG

• ECG can be recorded --- on CRO
--- on a graph paper.

• Speed of electrocardiograph -- 25 mm / sec

ecg paper – on X axis – time, 1mm = .04 sec
on Y axis -- voltage , 1mm = .1 mv
• Waves of ECG - due to depol and repolarization, not due to contra.
( ie,recording electrical activity, not mechanical activity )
• When depol wave moves towards recording electrode ( exploring
electrode) -upward deflection -- +ve wave obtained
- When depol moves away from the recording electrode - downward
-- deflection -ve wave obtained
Normal ECG -----( Lead II )
• Normal ECG has --waves -- P, QRS complex, T
-segments--- PQ/PR segment, ST segment
- intervals----PR interval, QT interval,
RR interval
• P wave
+ve deflection
Duration = .08 - .1 sec
Amplitude 0.1 to .3 mv
• ---due to atrial depolarization

• Magnitude of p --- a guide to the functional activity of atria.

• In mitral stenosis – left atrium is hypertrophied & P wave becomes
larger & prolonged
• In atrial fibrillation – p wave absent
• In atrial ectopic ---- inverted p wave
QRS complex
• --- due to ventricular depol
- (-atrial repolarization is masked by ventr depol )
Consists of 3 waves—Q, R, S
Duration .08 ms -- .12 ms
Amplitude 1 – 3 mv ( top of R  S)
Q –due to depol of interventricular septum from left to right
R – depol of apex of both ventricles
S – depol of basal part of vent
Clinical significance-
Deep Q wave ( >.2mv) –is a sign of MI
Tall R wave ( >1.3 mv) seen in vent hypertrophy
QRS duration > .12 sec – heart block
T wave
• -represents vent repol.
• Wider – because repol is slower
• Duration 0.15 -- 0.3 sec, amplitude 0.1 – 0.3 mv

• Clinical significance
• Inverted T wave -- important sign of MI
• Tall & peaked T wave -- hyperkalaemia ( increased K+ )

• U wave --- rarely seen

• due to repol of papillary muscles
• Prominent in hypokalaemia
Segments
Isoelectric lines in b/w the waves

PR segment
ST segment

PR segment ( PQ segment)
Space b/w end of P wave & beginning of QRS complex
Duration .04 --0.1 sec
--depol of AVN , bundle of His & bundle branch
• ST segment
• period b/w --end of QRS complex & beginning of T wave
“ “ end of vent depol to the beginning of vent. repol
• Duration 0.04 –0.08 sec
• Clinical significance
• In MI --- ST seg is elevation
• In myocardial ischemia– ST seg depressed

• J point
• Point b/w end of S wave and beginning of ST segment
• Point of zero voltage
• Helps in assessing ST seg elevation
• Intervals
• -- include waves and segments

• PR interval
• Interval from beginning of P wave to the beginning of Q or R wave
• Time b/w onset of atrial depol and onset of vent depol
• Atrial depol + conduction time in bundle of His
• P wave + PQ segment
• normal duration .12 --- .20sec
• If PR int > .2 – indicates AV conduction block
• QT interval

• Interval from beginning of Q wave to the end of T wave

• --ventr depol & ventr repol
• Nl duration 0.40 -- 0.43 sec
• QT int – shortened in hyperkalaemia

• PP interval
• interval b/w peaks of 2 successive P waves
• RR interval
• Interval b/w 2 successive R waves
• Normal duration = 0.8 sec
• for calculating heart rate
• HR = 60 / RR int. in sec
• = 60 / 0.8 = 75 / min

Other method
• H R = 1500 / RR int. in mm
ECG --- 2nd class
Recording of ECG
The basis of ECG recording is formed by postulates of William Einthovan
Postulates
1) Body acts as a volume conductor & heart acts as a current source.
Heart is a dipole situated in the centre of volume conductor.
• 2 ) In any volume conductor, if an equilateral triangle is drawn with
electric source at the centre, the sum of the potentials at the 3
apices of the triangle is equal to 0 at any time .
 3 ) Einthovan’s triangle
• William Einthovan approximated an equilateral triangle in the body
with heart at the centre , and triangle is formed by the points where
the left arm,right arm and left leg join with the trunk. This is
Einthovan’s triangle .
• 4) The 3 limbs ( Lt arm , Lt leg & Rt arm ) are considered as
extensions of this volume conductor so that electrodes can be placed
anywhere on the limbs . It will not make any difference to the ECG
pattern.

• Fig
ECG LEADS
• Leads - electrodes which can pick up electrical activities from the body
surface.
• They are placed on the body surface & connected to the ECG machine for
measuring p.d b/w 2 points .
• Leads – 2 types
• Bipolar leads
• Unipolar leads

• Bipolar leads
* Both electrodes are active ( both can pick up electrical activity)
One is connected to the +ve and other is connected to –ve terminal of
ECG machine
* Bipolar leads measure the p.d b/w 2 points
• Unipolar leads

• Here 1 electrode is active.

It is the recording electrode or exploring electrode .
• It is connected to the +ve terminal of ECGraph

• The other electrode is inactive -- indifferent electrode, it is kept at 0

pot

• Unipolar leads measure the absolute pot at a point

• Leads - total 12

• bipolar limb leads 3 -LI , LII, LIII

• Augmented unipolar limb leads – 3 - aVR , aVL, aVF

• Unipolar chest leads – 6 - V1 , V2, V3, V4, V5, V6

Bipolar Limb Leads
• 2 electrtodes- both are active.
• They measure the p.d b/w 2 points.
• Bipolar limb leads are designated as LI, LII, & LIII
• electrodes are connected to the Lt arm(LA), Rt arm ( RA), & Lt foot
(LF)

• LI measures the p.d b/w LA & RA (LA +ve

LII measures the p.d b/w RA & LF (LF +ve)
• LIII measures the p.d b/w LA & LF (LF +ve)
Einthovans Law
The 3 bipolar limb leads represents a closed circuit.
According to Kirchoff’s law ( closed circuit law ), the algebraic sum of
the potentials sequentially recorded in a closed circuit is 0

• Ie LI + LII + LIII = 0

But Einthovan reversed the polarity of LII in order to get +ve waves
in all 3 bipolar leads.
Eq becomes
LI - LII + LIII = 0 or LI + LIII = LII
So if the electrical pot of any 2 standard bipolar limb leads at any
instant are known, the pot of 3rd lead can be calculated by using the
eq LI+ LIII =LII . This is known as Einthovans Law
• Electrodes are placed just above the wrist on the arms &
just above the ankles on the leg.
-electrodes – gel is applied – to decrease resistance and to get proper
contact with skin
Earthing –RL --for the electrical protection of the patient and to
eliminate electrical interference in the recordings.
RL from right leg
Unipolar leads
• It records the absolute potential at a point

• Exploring electrode is connected to +ve terminal

• Indifferent electrode - zero pot --- -ve terminal

• Unipolar leads --- different types

• Unipolar limb leads--- VR, VL, VF

• Unipolar chest leads—V1, V2 , V3 , V4, V5, V6

• Unipolar limb leads –include VR, VL, VF ( now they are not used -
they are changed into aVR, aVL, aVF )
here active electrode is placed over one limb eg
• VL – active electrode on Lt arm – measures - pot at Lt arm
• VF – “ Lt Foot - “ pot at LT foot
• VR— “ Rt arm - “ pot at Rt arm

• Indifferent electrode is obtained as follows and connected to –ve

terminal of ECGraph
• In a volume conductor , the sum of potentials at the apices of an
equilateral triangle with current source at the centre is 0
(2nd postulate)
• Indifferent electrode is made by connecting the three limbs rt arm, Lt
arm & Lt foot each through a high resistance of 5000 ohm to a
common terminal . Pot at that point is 0
• This common terminal is called Wilsons’ central terminal ( WCT )
• Exploring electrode is placed on one limb and the indifferent
electrode is connected to WCT
• Here the magnitude of recording is small
• Gold berger modified the unipolar limb leads– pot can be amplified
r augmented—50% greater

Thus unipolar limb leads --- augmented unipolar limb leads

• Augmented limb leads ---- aVR, aVL, aVF
• Here active electrode is from one of the limbs and
indifferent electrode is obtained by connecting the other 2 limbs to
WCT through 5000 ohm resistance each

• Eg aVR – active electrode is from RA and indifferent electrode is

from LA & LF

• aVR = 3/2 VR , aVL = 3/2 VL , aVF = 3/2 VF

aVR, aVL, aVF
Unipolar chest leads
• Chest leads give a greater magnitude of potential as the electrode is near the heart.
• The exploring electrode is placed on different positions on the chest to get multiple
leads.
• Indifferent electrode is placed on WCT
• Positions of aVR,aVL ,aVF &
chest leads are as follows
-----------------------------------------------
• V1 -4th intercostal space to the
rt of sternum
• V2-4th ICS to the left of sternum
• V3 - midway b/w V2 & V4
• V4 -in the left 5th ICS
• V5 -5th Lt ICS in anterior axillary line
• V6 –5th left ICS in mid axillary line
• Only in aVR – all waves are –ve
• Expl electrode is in the rt arm & depol wave from SAN is moving
away from the expl electrode ie, to the left.
Recording of ECG - procedure
• The subject lies in a supine position with the chest bare
• Limb leads and chest leads are connected to the subject
• Earthing is done

• speed of machine 25 mm/sec .

• Recording is done on ECG paper with the help of a heated stylus.

• When current passes through the stylus, it gets heated and it melts
the wax of wax coated paper,
standardisation
It is by applying 1mv of current – we should get 10 mm height and ends
are at right angles to each other

• Heart rate calculation

• Speed of ecg machine = 25 mm/sec

• Distance moved by paper in 1 minute =25 X 60 = 1500
• H R = 1500 / RR int in mm
• ECG -3rd class
Clinical applications of ECG
• Abnormal ECG pattern are significant in the diagnosis of different
pathological conditions like

• 1 Injury – ischemia or death of myocardial tissues --MI

• 2 disorders of cardiac rhythm- arrythmias

• 3 conduction defect -- heart block

• 4 changes in the ionic composition of blood

• Use of ECG in the diagnosis of Arrythmias

• Cardiac arrhythmias--- it is a disturbance in the heart rate or rhythm

Causes 1 ) disorders of impulse production
2 ) disorders of impulse conduction

1) Disorders of impulse production –sinus tachycardia-}SAN pacemaker

sinus bradycardia --} “ “
sinus arrhythmia----} “ “

ectopic / abnormal pacemaker---pacemaker other than SAN

• 2) disorders of impulse conduction ---conduction block = heart block
------ accelerated AV conduction

• Conduction block - SAN Block

- AVN Block---incomplete HB-1st degree HB
--2nd degree HB
--wenke back phenome
---complete HB
--BB Block
Accelerated AV conduction -- Wolf Parkinsons White syndrome
( WPW syndrome)
• Normal impulse production at SAN
normal sinus rhythm = 70 / min
• Sinus Tachycardia
increased impulse production, HR > 100 / min
(seen in fever, exercise, anxiety etc )
• ECG – normal with short RR interval .

Sinus bradycardia.
Decreased HR--- HR < 60 / min
(seen in athlets)
ECG –normal with prolonged RR int.
• Sick sinus syndrome
• Diseases affecting SAN – cause marked bradycardia., along with
dizziness & syncope ( unconsciousness)
• Treatment – artificial pacemaker

• Sinus Arrythmia
• H R changes with different phases of resp.
• During inspiration – HR increased
• During expiration – HR decreased.
• ECG – Nl , RR int varies according to HR
• Ectopic pacemaker
in pathological conditions – parts of conducting system other than SAN
–produce impulses. –ectopic focus or ectopic pacemaker
• Abnormal beat comes earlier than normal expected beat –
extrasystole, or premature beat
• Ectopic focus –--- AVnode, bundle of His, Purkinje system, atria, -.
. vent
• If it discharges at a rate higher than that of SAN----paroxysmal
tachycardia or atrial flutter.
• Ectopic focus in atrium– 150- 200 / min – atrial tachycardia
• If HR > 200 /min --- atrial flutter.
• If atrial rate > 300 / min – atrial fibrillation
• Conduction block
• Defect in transmission of impulses generated in SAN
Block can occur anywhere
• SAN block
• Impulses from SAN are blocked from entering the atrial muscle.
• Whole heart beat is lost
• Then AVN becomes pacemaker –heart starts functioning
• Atrioventricular block
--Defect in transmission of impulses from atria to ventricle
--Incomplete HB
--Partial disturbance of conduction b/w atria and vent—first degree
- second degree
First degree HB- all atrial impulses reach vent.
Increased delay in AVN ---slow conduction --- PR int prolongs
Atria : vent = 1:1
• Second degree HB
--- all atrial impulses are not conducted to vent .
-After 2 or 3 atrial contraction , 1 vent contr occurs.
- Atrial rate : vent rate = 2:1 , 3 : 1
• ECG – vent beat QRST missing
• 2:1 – after 2 atrial contr – I vent contr
• 3:1 - after 3 atrial contr – 1 vent contr
• Wenkebach phenomenon--- gradual prolongation of PR int with
every successive beat and then one QRS complex is dropped, then
again normal pattern with prolongation of PR int .. The cycle is
repeated .
• Complete HB or 3rd degree HB
• Complete interruption of conduction b/w atria & vent
• atria and vent beat at different rates,
• vent beat with its own rhythm ----Idioventricular rhythm (ivr)

- 15 – 40 / min ( ivr) – inefficient pumping of heart ---cerebral

ischemia—fainting –Stokes Adams syndrome– if it exceeds 1or 2 min –
loss of consciousness, convulsions -- death

• Treatment -- artificial pacemaker

• Accelerated AV conduction
• Normally the conducting pathway b/w Atria and Ventricle is AVN
• People with WPW syndrome have an additional nodal tissue called
Bundle of Kent –connect atria and ventricle
It conducts impulses faster than AVN & bundle of His to one ventricle
therefore - One vent excites earlier than other
• Bundle branch block
• Block of one of the branches of bundle of His

• In Rt Bundle branch block—block in Rt branch

- Lt “ “ - block in Lt branch
-------- one ventricle is excited early

• In Rt BBB, Lt vent contracts earlier than Rt vent

• In Lt BBB, Rt vent “ “ Lt vent
Changes in ECG due to ionic changes in blood
• Electrical activities of heart depends upon distribution of ions
• If there is any change in ionic conc, it will affect ECG
• K+
• Normal ECF [K+] = 4 – 5.5 meq/ L
• Hyperkalemia increased K+ in ECF

• ECG -- --- QRS complex is prolong

• T wave – tall and peaked – due to altered repol of myocadial cells
• Hypokalemia

• Decrease in [K+] in ECF

• ECG
• PR int prolongation
• ST segment depression
• T wave inversion
• Prominent U wave
• Na+ -
- normal conc in serum 135 – 145 m eq/ L
- decrease in conc –reduces electrical activity
- ECG -- low voltage waves

Ca+
• Hypocalcemia –decrease in [Ca 2+) in ecf
• ECG – duration of ST seg and QT interval are prolonged.
• Hyper calcemia increase in Ca2+
• ECG – decrease duration ST seg and QT interval
Myocardial Ischemia
• When coronary blood flow decreases due to atherosclerosis or any
other reason – causes deficiency of blood and Oxygen
• ECG -- ST seg --- depression
• -- T wave inversion

• Myocardial Infarction
• When Myocardial ischemia ------severe - M I
• ECG – ST seg elevation
• T wave inversion
• -- deep Q wave
• End end end