ECG
ECG is the algebraic sum of action potential of all cardiac muscle fibres , recorded extracellularly during the
cardiac cycle.
Procedure of graphical recording of electrical activity of heart- Electrocardiography
Graphical recording is the Electrocardiogram
There are 12 standard lead to record ECG
The lead is not a single wire but a combination of two wires and their electrodes to make a complete circuit
between the body and the machine
LEADS:
1. BIPOLAR LEADS (3)
2. UNIPOLAR LEADS:
i. Unipolar Augmented Leads (3)
ii. Unipolar Chest leads (6)
BIPOLAR LIMB LEADS
Both the electrodes are active
One active terminal connected to the positive terminal and the other connected to the negative terminal of
the ECG machine
It records potential difference between the two electrodes placed at different sites
They are also called as STANDARD LIMB LEADS
Einthoven’s Triangle:
is an equilateral triangle formed by joining leads I, II & III.
Einthoven’s Law:
States that if electrical potentials of any two of the three bipolar leads are known at any given instant,
the third can be determined mathematically.
Lead I + Lead III = Lead II
(Triangle Law of Vector)
UNIPOLAR AUGMENTED LIMB LEADS
There are 3 augmented unipolar limb leads:
2 electrodes: one active and other indifferent.
1. aVR
2. aVL
3. aVF
Active electrodes act as positive and indifferent electrodes act as negative terminal
Indifferent electrode is created by connecting the other two limb electrodes together.
Bipolar Active
Leads Electrodes
LEAD 1 RA LA
LEAD 2 RA LL
LEAD 3 LA LL
Lead 2 is preferred for rhythm abnormalties (bcz it lies close to mean electrical axis of heart- 59°)
Uniopolar Active Indifferent
Augmented Electrodes Electrodes
Leadseads
aVR RA LA+LL
aVL LA RA+LL
aVF LL RA+LA
UNIPOLAR CHEST LEADS
These leads record the potential in transverse plane
They are from V1 to V6
“V” stands for voltage
Indifferent electrode is created by connecting all three limb electrodes (right arm, left arm, and left leg)
together through high resistance.
Unipolar Chest Active Indifferent
Leads Electrode Electrodes
V1 Rt 4th ICS RA+LA+LL
V2 Lt 4th ICS RA+LA+LL
V3 b/w V2 & V4 RA+LA+LL
V4 Lt 5th ICS @MCL RA+LA+LL
V5 Lt 5th ICS @ AAL RA+LA+LL
V6 Lt 5th ICS @ MAL RA+LA+LL
NORMAL ECG WAVE FORMS
1. P WAVE
Configuration :
First positive deflection
Upright , rounded or pointed
Cause: Atrial depolarization
Amplitude: 0.2 – 0.3mV
Duration: 0.08- 0.1sec
2. Q WAVE
Configuration:
It is the initial small negative deflection in QRS complex
Cause: Septal depolarization
3. R WAVE
Configuration:
It is the positive deflection in QRS complex
Prominent ,pointed
Cause: It represents depolarization of interventricular apex and major portion of both ventricles
Amplitude: Should not exceed 2.5mV
4. S WAVE
Configuration:
It is the second negative deflection in the QRS complex
It follows the R wave
Cause: It represents depolarization of more basal parts of ventricles
Amplitude: 0.4 mV
5. QRS COMPLEX
Cause: Ventricular depolarization
Duration: 0.08-0.1sec
Amplitude: 1mV
6. T WAVE
Configuration:
Last positive dome shaped deflection
Normally in the same direction as QRS complex because ventricular repolarization follows a path opposite to
depolarization
Cause: Ventricular repolarization
Duration: 0.2sec
Amplitude: 0.2- 0.3mV
7. U WAVE
Configuration:
Small, rounded positive wave
Cause: Due to slow repolarization of papillary muscles
8. J POINT
It is a point at end of S wave and start of the ST segment
It is a point of no electrical activity
It is important in assessing ST segment elevation or depression
SEGMENTS:
1. P-R Segment
2. S-T Segment
Segments are iso-electric
1. P-R SEGMENT
End of P wave and beginning of QRS complex
Duration: 0.04-0.08 sec
It represents conduction pause at AV Node
2. ST SEGMENT
End of S wave to beginning of T wave
Duration: 0.04 to 0.08 sec
It is isoelectric .
INTERVALS
1. PR interval
2. QT interval
3. RR interval
1.P-R INTERVAL
Interval from the beginning of P wave to the beginning of QRS complex
It represents atrial depolarization and AV conduction time including AV nodal delay
Duration: 0.12 to 0.16 sec @HR 72/min
Clinical significance: Prolonged PR interval indicates AV conduction block
[Link] INTERVAL
Interval from the beginning of Q wave to the end of T wave
Duration: 0.40 to 0.43 sec
Clinical significance: Prolonged in ischemia , Ventricular conduction defect
[Link] INTERVAL
Time interval between two consecutive R waves (peaks)
Clinical significance: Signifies the duration of one cardiac cycle
Heart rate / min = 60 / R-R interval in sec
OR
Heart rate / min = 1500/ No. of small divisions
between R-R interval
Mean Electrical Axis:
Normal Axis ranges from -30° to +110° degree.
Mean QRS vector is found to be at +59°
Deviation beyond -30 = Left Axis Deviation (LAD)
Deviation beyond +110 = Right Axis Deviation (RAD)
APPLIED ASPECTS- ABNORMAL ECGS
Conduction Disorders
1. SA Nodal Block
2. AV Nodal Block
3. Bundle Branch Block
SA NODAL BLOCK
Blockage of impulse conduction from SAN to AVN
Initially heart stops for around 2 cardiac cycles, then
AVN takes charge of pacemaker.--> AV Nodal rhythm
This is aka Sick Sinus Rhythm
AV NODAL BLOCK
may manifest as
1. Incomplete - 1st and 2nd degree Heart Block
2. Complete Heart block
1st degree Heart Block
Slowing of conduction from AVNode.
Prolongeeeeeeeed PR interval. (>0.20s)
2nd Degree Heart Block
a. Wenckebach Phenomenon/
Mobitz Type 1 Block:
Progressive prolongation of PR interval and
subsequent missing of conduction of Mobitz Type 2 Heart Block
one impulse to ventricle.
b. Mobitz Type 2
Periodic Failure of conduction of impulse.
Can be 2:1 or 3:1 or 4:1 block
(2:1 means 2 p waves with 1 qrs complex- out
of 2 impulses generated one is conducted to
the ventricle)
3rd Degree Heart Block/ Complete Heart Block
Complete atrioventricular Dissociation.
Atria and ventricle beats by their own rhythm.
Bundle Branch Blocks
1. Left Bundle Branch Block/ LBBB
Prolonged QRS Complex
QRS duration > 0.12s (3 small squares)
[Link] Bundle Branch Block/ RBBB
Prolonged QRS Complex
QRS > 0.12s (3 small squares)
EXTRA POINTS
How can u investigate patient with Chest pain?
1. ECG
2. Biomarkers:
Cardiac Troponin: Troponin I
Creatinine Kinase- MB
LDH
SGOT/SGPT
3. Echocardiography
4. Coronary Angiography
5. CT Coronary Angiography
ECG changes in MI:
1. ST segment elevation
2. ST segment depression
3. T inversion
4. Pathological or deep Q wave
5. New onset LBBB
How will you treat a patient with MI?
1. Antiplatelets: Aspirin , Clopidogrel
2. Anticoagulants: Heparin
3. Anti anginal: Nitroglycerine (Vasodilator)
4. High dose Statin: lower Cholesterol
5. Morphine for Pain
6. Defnitive Treatment:
A. Medical Management:
Thrombolytics: Streptokinase
B. Surgical Management:
Percutaneous Coronary Intervention/ Angioplasty
Coronary Artery Bypass Graft (CABG)