Electrocardiogram

ECG/EKG
Dr. PANKAJ
 Electrocardiogram

When impulses passes through heart then

electrical current also spreads to the surrounding
tissues and to surface of body. When electrodes
are placed on the surface then it can record the
electrical activity . This is known as EC G.
 ECG paper
-ECG paper: contains small and large squares.
-Each small square is 1 mm and large square is 5mm
-Time is measured along horizontal line and each small
square is 0.04 sec and each large square is 0.2 sec.
-Voltage is measured along vertical line and 10 mm is equal
to 1 mV
-ECG paper moves at 25 mm/s speed, i.e. 1500 squares/min
 ECG leads
3 t ypes o f le ads :
Hor izont al pl ane leads :
1.Chest leads/precordial leads: V1, V2, V3,
V4,V5,V6
Fro nta l p la ne leads :
2.Bipolar leads/standard/Einthoven’s leads:
I,II,III
3.Augmented unipolar leads: aVR, aVL, aVF
 Placement of leads
Augmented leads:
aVR: right arm
aVL: left arm
aVF: left foot

Ch est le ad s
V1: in 4th ICS at right sternal border
V2: in 4th ICS at lft sternal border
V3: midway between V2 and V3
V4: 5th ICS in lft MCL
V5: anterior axillary line in 5th ICS
V6: mid axillary line in 5th ICs
12 leaded ECG/EKG
Chest leads
Einthoven’s triangle
Einthoven’s triangle
Hexaxial reference system
 In tri nsi c Co ndu cti on Sys tem
Functi on : in iti ate & d istri bute imp ulse s s o heart
depol ari zes & con trac ts in o rd erl y man ner from atri a to
ventri cles .

SA node

AV node
Bundle of His
Bundle Branches

Purkinje fibers
 In tri nsi c Co ndu cti on Sys tem
Functi on : in iti ate & d istri bute imp ulse s s o heart
depol ari zes & con trac ts in o rd erl y man ner from atri a to
ventri cles .

SA node

AV node
Bundle of His
Bundle Branches

Purkinje fibers
 In trin sic C ard ia c Con duct ion
Sy stem
Approximately 1% of cardiac muscle cells are
autorhythmic rather than contractile

75/min

40-60/min

30/min
 ECG D eflectio n Wa ves

(Pacemaker) Atrial repolarization

 ECG D eflectio n Wa ves

(Pacemaker) Atrial repolarization

 ECG D eflecti on Wa ve
Irreg ularit ies

Enlarged QRS =
Hypertrophy of
ventricles
 ECG D eflecti on Wa ve
Irreg ularit ies

Prolonged QT
Interval =

Repolarization
abnormalities
increase chances
of ventricular
arrhythmias.
 ECG D eflecti on Wa ve
Irreg ularit ies

Elevated T wave :
Hyperkalemia
 ECG D eflecti on Wa ve
Irreg ularit ies

Flat T wave :
Hypokalemia
or ischemia
 ECG D eflecti on Wa ve
Irreg ularit ies

Elevated T wave :
Hyperkalemia
 Hea rt B locks
P T
Normal ECG
QRS

Not a QRS for

2nd Degree Block
each P wave

No P waves.
Rate
3rd Degree Block determined by
autorhythmic
cells in
 Card ia c Cy cle
 All events associated with a single heart
beat including atrial systole & diastole
followed by ventricular systole &
diastole. (V. Systole) (V. Diastole)
Systolic BP
Diastolic BP
 ECG D eflectio n Wa ves
60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
Frank St arlin g La w of t he
Heart
 The more cardiac muscle is stretched within
physiological limits, the more forcibly it will
contract.
 Rubber band analogy
 Increasing volumes of blood in ventricles
increase the stretch & thus the force
generated by ventricular wall contraction.
 Greater stretch means more blood volume is
pumped out, up to physical limits.
Frank St arlin g La w of t he
Heart
 The more cardiac muscle is stretched within
physiological limits, the more forcibly it will
contract.
 Rubber band analogy
 Increasing volumes of blood in ventricles
increase the stretch & thus the force
generated by ventricular wall contraction.
 Greater stretch means more blood volume is
pumped out, up to physical limits.
 Frank St arlin g La w of t he
Heart

Increased blood volume = Increased force to pump blood

increased stretch of myocardium out.
 ECG waves & genesis
P wave: normally upright , signifies atrial depolarisation
<2.5mm height and 0.11 sec duration

QRS complex: ventricular depolarisation N: 0.08 – 0.12 sec

T wave: ventricular repolarisation

U wave: it is positive deflection which comes after T wave. Is due to

slow repolarization of interventricular purkinje fiber. Often it is not
evident in ECG

R-R interval: distance between two successive R wave

P-R interval : time taken for impulse to travel from SA node to ventricles
0.12-0.22sec

QT interval: total time for ventricular depolarisation and repolarisation

<0.42 sec
 Axis
Normal axis lies between -30 and +110 degree

Left axis deviation: -30 and -90 degree

Right axis deviation: +110 and +/- 180 degree

Intermediate axis : -90 and +/- 180 degree

Electrical axis of heart
 Tec hn iqu e of rea din g and report ing ECG

1.Heart rate
2.Rhythm
3.Voltage
4.Axis
5.P wave
6.PR interval
7.QRS complex
8.ST segment
9.T wave
10.U wave
11.QT duration
12.Final diagnosis
Standardisation
 Determination of axis
Many methods are there
Measure the overal
height in leads I and
aVF and then plot in
graph paper. Then
find the vector angle.
 Heart rate
HR= 1500/ RR interval in small squares
 Uses of ECG
1. Aids diagnosis, prognosis and treatment
2. Gives information regarding functioning
of atria and ventricles
3. Identify damage to heart (infarction)
4. Identify abnormal rhythm and rate
5. Identify change in size of chambers of
heart
 Some A bn orm ali ti es i n
ECG
P wa ve :
a) p wave wide and notched (p-mitral)-left atrial hypertrophy
b) p wave tall and peaked ( p-pulmonale) –right atrial hypertrophy

QRS compl ex:

Tall QRS- ventricular hypertrophy
Tall peaked T wave- hyperkalemia
Low or inverted T wave- myocardial ischemia

U wave :
Prominent U wave- hypokalemia

ST seg men t:
Elevated with convexity upward-myocardial infaction
Depressed- angina pectoris
PR i nter va l:
Increased PR interval -Bradycardia
Decreased PR interval- tachycardia
No PR interval- complete heart block
Normal sinus rhythm
RVH
Coronary infarction
Sinus tachycardia
Ventricular tachycardia following
extrasystole
Ventricular fibrillation
ECGs (lead II) showing
abnormal rhythms
 A:Respiratory sinus
arrhythmia.
 B:Sinus arrest with
vagal escape.
 C:Atrial fibrillation.
 D:Premature
ventricular complex.
 E:Complete
atrioventricular block.
 Wol f pa rki nson white ( WPW )
syndro me:
 Extra path is formed between atrium and ventricle
 Features:
3. Short PR interval
4. Wide QRS complex
5. Delta wave

Heart blo ck:

1.First degree heart block: prolonged PR interval
2.Second degree heart block
a. Mobitz type I b. mobitz type II
3.Complete heart block