Electrocardiogram
Electrocardiography
• Electrocardiography is the technique by which
electrical activities of the heart are studied.
• The spread of excitation through myocardium
produces local electrical potential.
• This low-intensity current flows through the body,
which acts as a volume conductor.
• This current can be picked up from surface of the
body by using suitable electrodes and recorded in
the form of electrocardiogram.
• This technique was discovered by Dutch
physiologist, Einthoven Willem
Electrocardiogram
• Electrocardiogram (ECG) is the graphical record
of electrical activities of the heart
Uses of ECG
Electrocardiogram is useful in determining and
diagnosing the following:
1. Heart rate
2. Heart rhythm
3. Abnormal electrical conduction
4. Poor blood flow to heart muscle (ischemia)
5. Heart attack
6. coronary artery disease
7. Hypertrophy of heart chambers.
Electrocardiographic Grid
• The paper that is used for recording ECG is
called ECG
paper.
• ECG machine amplifies the electrical signals
produced from the heart and records these
signals on a moving ECG paper.
• Electrocardiographic grid refers to the markings
(lines) on ECG paper.
• ECG paper has horizontal and vertical lines at
regular intervals of 1 mm. Every 5th line (5 mm)
is thickened.
Duration:
• Time duration of different ECG waves is plotted
horizontally on X-axis.
1 mm = 0.04 second
5 mm = 0.20 second
Amplitude:
• Amplitude of ECG waves is plotted vertically on
Y-axis.
1 mm = 0.1 mV
5 mm = 0.5 mV
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.
ECG is recorded in 12 leads, which are generally
classified into two categories.
I. Bipolar leads
II. Unipolar leads
Bipolar Limb Leads
• Bipolar limb leads are otherwise known as
standard
limb leads.
• Two limbs are connected to obtain these leads and
both the electrodes are active recording
electrodes, i.e. one electrode is positive and the
other one is negative
Standard limb leads are of three types:
a. Limb lead I
b. Limb lead II
c. Limb lead III.
Lead I
• Lead I is obtained by connecting right arm and
left arm.
• Right arm is connected to the negative terminal of
the instrument and the left arm is connected to
the positive terminal.
Lead II
• Lead II is obtained by connecting right arm
and left leg.
• Right arm is connected to the negative terminal of
the instrument and the left leg is connected to the
positive terminal
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
one electrode is active electrode and the other one is
an indifferent electrode.
Unipolar leads are of two types:
1. Unipolar limb leads
2. Unipolar chest leads.
1. Unipolar Limb Leads
• Unipolar limb leads are also called augmented
limb leads or augmented voltage leads.
• Active electrode is connected to one of the limbs.
• Indifferent electrode is obtained by connecting the
other two limbs through a resistance.
Unipolar limb leads are of three types:
i. aVR lead
ii. aVL lead
iii. aVF lead.
i. aVR lead
• Active electrode is from right arm.
• Indifferent electrode is obtained by connecting
left arm and left leg.
ii. aVL lead
• Active electrode is from left arm.
• Indifferent electrode is obtained by connecting
right arm and left leg.
iii. aVF lead
• Active electrode is from left leg (foot).
• Indifferent electrode is obtained by connecting
the two upper limbs.
2. Unipolar Chest Leads
• Chest leads are also called ‘V’ leads or precordial
chest leads.
• Indifferent electrode is obtained by connecting the
three limbs, viz. left arm, left leg and right arm,
through a resistance of 5000 ohms.
• Active electrode is placed on six points over the
chest
• This electrode is known as the chest electrode and
the six points over the chest are called V1, V2, V3,
V4, V5 and V6.
• V indicates vector, which shows the direction of
current flow.
Position of chest leads:
V1 : Over 4th intercostal space near right sternal
margin
V2 : Over 4th intercostal space near left sternal
margin
V3 : In between V2 and V4
V4 : Over left 5th intercostal space on the mid
clavicular line
V5 : Over left 5th intercostal space on the anterior
axillary line
V6 : Over left 5th intercostal space on the mid
axillary line
WAVES OF NORMAL ECG
• Normal ECG consists of waves, complexes,
intervals and segments.
• Waves of ECG recorded by limb lead II are
considered as the typical waves.
• Normal electrocardiogram has the following
waves, namely P, Q, R, S and T
• Einthoven had named the waves of ECG starting
from the middle of the English alphabets (P)
instead of starting from the beginning (A).
Major Complexes in ECG
1. ‘P’ wave- atrial complex
2. ‘QRS’ complex- initial ventricular complex
3. ‘T’ wave- final ventricular complex
‘P’ WAVE
• ‘P’ wave is a positive wave and the first wave
in ECG. It is also called atrial complex
Cause - ‘P’ wave is produced due to the
depolarization of atrial musculature.
• Depolarization spreads from SA node to all
parts of atrial musculature.
• Atrial repolarization is not recorded as a
separate wave in ECG because it merges with
ventricular depolarization (QRS complex)
Duration
• Normal duration of ‘P’ wave is 0.1 second.
Amplitude Normal amplitude of ‘P’ wave is 0.1
to 0.12 mV.
Morphology
• ‘P’ wave is normally positive (upright) in
leads I, II, aVF, V4 , V5 and V6 .
• It is normally negative (inverted) in aVR.
• It is variable in the remaining leads, i.e. it
may be positive, negative, biphasic or flat
Clinical Significance
Variation in the duration, amplitude and morphology
of ‘P’ wave helps in the diagnosis of several cardiac
problems such as:
1. Right atrial hypertrophy:
• ‘P’ wave is tall (more than 2.5 mm) in lead II.
• It is usually pointed
2. Left atrial hypertrophy:
• It is tall and broad based or M shaped
3. Hyperkalemia:
• ‘P’ wave is absent or small
4. Atrial fibrillation: ‘P’ wave is absent
‘QRS’ COMPLEX
• ‘QRS’ complex is also called the initial ventricular
complex.
• ‘Q’ wave is a small negative wave.
• It is continued as the tall ‘R’ wave, which is a
positive wave.
• ‘R’ wave is followed by a small negative wave, the
‘S’ wave.
Cause –
• ‘QRS’ complex is due to depolarization of
ventricular musculature.
• ‘Q’ wave is due to the depolarization of basal
portion of interventricular septum.
• ‘R’ wave is due to the depolarization of apical
portion of interventricular septum and apical
portion of ventricular muscle.
• ‘S’ wave is due to the depolarization of basal
portion of ventricular muscle near the
atrioventricular ring.
Duration-
• Normal duration of ‘QRS’ complex is between
0.08 and 0.10 second.
Amplitude
• Amplitude of ‘Q’ wave = 0.1 to 0.2 mV.
• Amplitude of ‘R’ wave = 1 mV.
• Amplitude of ‘S’ wave = 0.4 mV.
Morphology
• From chest leads V1 to V6, ‘R’ wave becomes
gradually larger. It is smaller in V6 than V5.
• ‘S’ wave is large in V1 and larger in V2. It gradually
becomes smaller from V3 to V6.
Clinical Significance
• Variation in the duration, amplitude and
morphology of ‘QRS’ complex helps in the
diagnosis of several cardiac problems such as:
1. Bundle branch block: QRS is prolonged or
deformed
2. Hyperkalemia: QRS is prolonged.
‘T’ WAVE
• ‘T’ wave is the final ventricular complex and is a
positive wave.
Cause
• ‘T’ wave is due to the repolarization of
ventricular musculature.
Duration-
• Normal duration of ‘T’ wave is 0.2 second.
Amplitude-
• Normal amplitude of ‘T’ wave is 0.3 mV.
Morphology-
• ‘T’ wave is normally positive in leads I, II and V5
and V6.
• It is normally inverted in lead aVR.
• It is variable in the other leads, i.e. it is positive,
negative or flat.
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. (a tall and broad-
based ‘T’ wave, with slight asymmetry).
2. Old age, hyperventilation, anxiety, myocardial
infarction, left ventricular hypertrophy and
pericarditis:
‘T’ wave is small, flat or inverted
3. Hypokalemia: ‘T’ wave is small, flat or inverted
‘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
INTERVALS AND SEGMENTS OF ECG
‘P-R’ INTERVAL
• ‘P-R’ interval is the interval between the onset of
‘P’ wave and onset of ‘Q’ wave.
• ‘P-R’ interval signifies the atrial depolarization and
conduction of impulses through AV node.
• It shows the duration of conduction of the
impulses from the SA node to ventricles through
atrial muscle and AV node.
Duration
• Normal duration of ‘P-R interval’ is 0.18 second
Clinical Significance
• Variation in the duration of ‘P-R’ intervals helps
in the diagnosis of several cardiac problems such
as:
1. It is prolonged in bradycardia
2. It is shortened in tachycardia
‘Q-T’ INTERVAL
• ‘Q-T’ interval is the interval between the onset
of ‘Q’
wave and the end of ‘T’ wave.
• ‘Q-T’ interval indicates the ventricular
depolarization
and ventricular repolarization, i.e. it signifies the
electrical activity in ventricles.
Duration
• Normal duration of Q-T interval is between 0.4
and 0.42 second.
Clinical Significance
1. ‘Q-T’ interval is prolonged in myocardial
infarction, hypocalcemia
2. ‘Q-T’ interval is shortened in hypercalcemia
‘S-T’ SEGMENT
• ‘S-T’ segment is the time interval between the
end of
‘S’ wave and the onset of ‘T’ wave.
Duration of ‘S-T’ Segment
• Normal duration of ‘S-T’ segment is 0.08 second.
Clinical Significance
• Variation in the duration of ‘S-T’ segment and its
deviation from isoelectric base indicates the
pathological conditions such as:
1. Elevation of ‘S-T’ segment occurs in anterior
or
inferior myocardial infarction
2. Depression of ‘S-T’ segment occurs in acute
myocardial ischemia, posterior myocardial
infarction, ventricular hypertrophy
‘R-R’ INTERVAL
• ‘R-R’ interval is the time interval between two
consecutive ‘R’ waves.
Significance
• ‘R-R’ interval signifies the duration of one
cardiac cycle.
Duration
• Normal duration of ‘R-R’ interval is 0.8 second.
Significance of Measuring ‘R-R’ Interval
Measurement of ‘R-R’ interval helps to calculate:
1. Heart rate
2. Heart rate variability.
1. Heart Rate-
• Heart rate is calculated by measuring the
number of ‘R’ waves per unit time.
Calculation of heart rate
• Time is plotted horizontally (X-axis). On X-axis,
interval between two thick lines is 0.2 sec
• Time duration for 30 thick lines is 6 seconds.
• Number of ‘R’ waves (QRS complexes) in 6
seconds (30 thick lines) is counted and
multiplied by 10 to obtain heart rate.
2. Heart Rate Variability
• Heart rate variability (HRV) refers to the beat-to
beat variations.
• Under resting conditions, the ECG of healthy
individuals exhibits some periodic variation in ‘R-
R’ intervals.
• This rhythmic phenomenon is known as
respiratory sinus arrhythmia (RSA), since it
fluctuates with the phases of respiration.
• ‘R-R’ interval decreases during inspiration and
increases during expiration
