Heart’s Electrical Conduction System:

1. Action Potential originates in the sinoatrial (SA) node and travel across the
wall of the atrium from the SA node to the atrioventricular (AV) node.
2. AP passes slowly through the AV node to give the atria time to contract.
3. They then pass rapidly along the bundle
of His, which extends from the
atrioventricular node. The bundle of His
divides into right and left bundle
branches and action potentials descend
rapidly to the apex of each ventricle
along the bundle branches.
4. APs are carried by the Purkinje fibers
from the bundle branches to the
ventricular walls.
5. The rapid conduction from the atrio-
ventricular bundle to the ends of the Purkinje fibers allows the ventricular
muscle cells to contract in unison, providing a strong contraction.

Electrocardiogram (ECG/EKG)
Electrocardiography is the process of producing
an electrocardiogram (ECG or EKG), a recording-a graph of voltage versus
time-of the electrical activity of the heart using electrodes placed on the skin.
These electrodes detect the small electrical changes that are a consequence of
cardiac muscle depolarization followed by repolarization during each cardiac
cycle (heartbeat).
In a conventional 12-lead ECG, ten electrodes are placed on the patient's limbs
and on the surface of the chest. The overall magnitude of the heart's electrical
potential is then measured from twelve different angles ("leads") and is
recorded over a period of time (usually ten seconds). In this way, the overall
magnitude and direction of the heart's electrical depolarization is captured at
each moment throughout the cardiac cycle.
There are three main components to an ECG: the P wave, which represents the
depolarization of the atria; the QRS complex, which represents the
depolarization of the ventricles; and the T wave, which represents the
repolarization of the ventricles.
During each heartbeat, a healthy heart has an orderly progression of
depolarization that starts with pacemaker cells in the sinoatrial node, spreads
throughout the atrium, and passes through the atrioventricular node down into
the bundle of His and into the Purkinje fibers, spreading down and to the left
throughout the ventricles. This orderly pattern of depolarization gives rise to the
characteristic ECG tracing. To the trained clinician, an ECG conveys a large
amount of information about the structure of the heart and the function of its
electrical conduction system. Among other things, an ECG can be used to
measure the rate and rhythm of heartbeats, the size and position of the heart
chambers, the presence of any damage to the heart's muscle cells or conduction
system, the effects of heart drugs, and the function of implanted pacemakers.
ECG Theory:
 depolarization of the heart towards the positive electrode produces a
positive deflection
 depolarization of the heart away from the positive electrode produces a
negative deflection
 repolarization of the heart towards the positive electrode produces a
negative deflection
 repolarization of the heart away from the positive electrode produces a
positive deflection

Electrodes and leads:

Electrodes are the actual conductive pads attached to the body surface. Any pair of
electrodes can measure the electrical potential difference between the two
corresponding locations of attachment. Such a pair forms a lead. However, "leads"
can also be formed between a physical electrode and a virtual electrode, known
as the Wilson's central terminal, whose potential is defined as the average potential
measured by three limb electrodes that are attached to the right arm, the left arm,
and the left foot, respectively.

Commonly, 10 electrodes attached to the body are used to form 12 ECG leads,
with each lead measuring a specific electrical potential difference.

Leads are broken down into three types: limb; augmented limb; and precordial or
chest. The 12-lead ECG has a total of three limb leads and three augmented limb
leads arranged like spokes of a wheel in the coronal plane (vertical), and
six precordial leads or chest leads that lie on the perpendicular transverse plane
(horizontal)
Electrode (10) placement for 12 lead ECG:
Electrode Name Electrode placement
RA On the right arm, avoiding thick muscle.
LA In the same location where RA was placed, but on the left arm.
RL On the right leg, lower end of inner aspect of calf muscle.
(Avoid bony prominences)
LL In the same location where RL was placed, but on the left leg.
V1 In the fourth intercostal space (between ribs 4 and 5) just to
the right of the sternum (breastbone)
V2 In the fourth intercostal space (between ribs 4 and 5) just to
the left of the sternum.
V3 Between leads V2 and V4.
V4 In the fifth intercostal space (between ribs 5 and 6) in the mid-
clavicular line.
V5 Horizontally even with V4, in the left anterior axillary line.
V6 Horizontally even with V4 and V5 in the mid-axillary line.
The common virtual electrode, known as the Wilson's central terminal (V W), is
produced by averaging the measurements from the electrodes RA, LA, and LL to
give an average potential of the body:
Vw=1/3(RA+LA+LL)
In a 12-lead ECG, all leads except the limb leads are unipolar (aVR, aVL, aVF, V 1,
V2, V3, V4, V5, and V6). The measurement of a voltage requires two contacts and
so, electrically, the unipolar leads are measured from the common lead (negative)
and the unipolar lead (positive).
Limb Leads:
Leads I, II and III are called the limb leads. The electrodes that form these signals are
located on the limbs – one on each arm and one on the left leg. The limb leads form the
points of what is known as Einthoven's triangle.
 Lead I is the voltage between the (positive) left arm (LA) electrode and right arm
(RA) electrode: I =LA-RA
 Lead II is the voltage between the (positive) left leg (LL) electrode and the right
arm (RA) electrode: II=LL-RA
 Lead III is the voltage between the (positive) left leg (LL) electrode and the left
arm (LA) electrode: III=LL-LA
Augmented Limb Leads:
Leads aVR, aVL, and aVF are the augmented limb leads. They are derived from
the same three electrodes as leads I, II, and III, but they use Goldberger's central
terminal as their negative pole. Goldberger's central terminal is a combination of
inputs from two limb electrodes, with a different combination for each augmented
lead. It is referred to immediately below as "the negative pole".
 Lead augmented vector right (aVR) has the positive electrode on the right
arm. The negative pole is a combination of the left arm electrode and the left
leg electrode:
aVR=RA-1/2(LA+LL)=3/2(RA-Vw)
 Lead augmented vector left (aVL) has the positive electrode on the left arm.
The negative pole is a combination of the right arm electrode and the left leg
electrode:
aVL=LA-1/2(RA+LL)=3/2(LA-Vw)
 Lead augmented vector foot (aVF) has the positive electrode on the left leg.
The negative pole is a combination of the right arm electrode and the left
arm electrode:
aVF=LL-1/2(RA+LA)=3/2(LL-Vw)
Precordial chest leads:
The precordial leads lie in the transverse (horizontal) plane, perpendicular to the
other six leads. The six precordial electrodes act as the positive poles for the six
corresponding precordial leads: (V1, V2, V3, V4, V5, and V6). Wilson's central
terminal is used as the negative pole.

How the Electrical Conduction Through the Heart Creates the ECG:
 P Wave: the depolarization being generated in and spreading through
the Sinoatrial node. The SA node is too small for its depolarization to be
detected on most ECGs. The depolarization travels through the atria,
towards the Atrioventricular node. The depolarization travels through the
largest amount of tissue in the atria, which creates the highest point in the P
wave.
 PR Segment: Depolarization travels through the AV node. Like the SA
node, the AV node is too small for the depolarization of its tissue to be
detected on most ECGs. This creates the flat PR segment.
 Q Wave: The action potential starts traveling down the left bundle branch
about 5 milliseconds before it starts traveling down the right bundle branch.
This causes the depolarization of the interventricular septum tissue to spread
from left to right. This gives rise to a negative deflection after the PR
interval, creating a Q wave.
  R Wave: Following depolarization of the interventricular septum, the
depolarization travels towards the apex of the heart, which creates the R
wave.
 S Wave: Then the depolarization travels throughout both ventricles from the
apex of the heart, following the action potential in the Purkinje fibers. This
phenomenon creates a negative deflection in all three limb leads, forming
the S wave on the ECG.
Repolarization of the atria occurs at the same time as the generation of the QRS
complex, but it is not detected by the ECG since the tissue mass of the ventricles is
so much larger than that of the atria.
 ST segment: Ventricular contraction occurs between ventricular
depolarization and repolarization. During this time, there is no movement of
charge, so no deflection is created on the ECG. This results in the flat ST
segment after the S wave. This indicates the plateau phase of action
potential.
 T Wave: The epicardium is the first layer of the ventricles to repolarize,
followed by the myocardium. The endocardium is the last layer to
repolarize. The plateau phase of depolarization has been shown to last longer
in endocardial cells than in epicardial cells. This causes repolarization to
start from the apex of the heart and move upwards. This creates the T wave.

 U wave: The U wave is hypothesized to be caused by the repolarization of

the interventricular septum. It normally has a low amplitude, and even more
often is completely absent.
Segments are isoelectric lines on ECG & intervals contains two or more
segments or intervals.

Heart Rate= 60/R_R interval (beats/minute)