Module 3: ECG

ECG complexes reflect the heart’s electrical activity.

The electrical cells generate and conduct electrical impulses that

result in:
1. Depolarization – the loss of electrical charge on the surface of a
membrane (electrical activation)
2. Contraction
3. Repolarization – the returning of a muscle to its resting state
(recovery)
Recording of these electrical events (depolarization and repolarization in
the atria and ventricles) produces the ECG or EKG
ECG - Electrocardiogram

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  ECG measures the size and force of the electrical impulse through
the atria and ventricles
 Care must be taken not to confuse electrical events (P-QRS-T
waveforms on the ECG) with their mechanical counterparts
(contraction and relaxation of the atria and ventricles)
 Mechanical events lag behind the heart’s electrical activity
 Atrial contraction follows the P wave
 Ventricular contraction follows the QRS interval
ECG Lead Systems:

• To understand the appearance of a given QRS complex (and other

information in an ECG) it is important to know 3 basic principles
for the ECG
• Principle #1: A wave of depolarization that approaches a
monitoring electrode (lead) records an upward (positive)
deflection on the ECG
• Principle #2: A wave of depolarization that moves away from a
monitoring electrode records a downward (negative) deflection in
an ECG
• Principle #3: A wave of depolarization that is perpendicular to a
monitoring electrode records an equiphasic (equally +ve and –ve)
QRS complex
• A standard ECG is recorded by viewing the heart’s electrical
activity from 12 leads (10 electrodes are placed on the body)
• Each lead records the heart’s electrical potential from its own
particular vantage point
• The reason so many leads are used is to provide as accurate a view
as possible of the heart

The 12 leads recorded in a standard ECG are:

• Leads I, II, III

• Leads aVR, aVL, aVF
• Leads V1, V2, V3, V4, V5, V6

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Lead I, II, III

• Referred to as standard limb leads

• Bipolar leads
• Record the difference in electrical potential between the LA, RA
and/or LL electrodes
• The heart can be seen to lie at the center of an equilateral triangle
known as Einthoven’s triangle
• The electrical field of this triangle is defined by the axes of the 3
standard limb lead

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Precordial Leads: V leads

• Unipolar electrode recordings that view the heart’s electrical

activity in the transverse (horizontal) plane
• Six V leads
• Accurate placement is very important
• If leads are not properly placed, the QRS can be altered
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Summary of the Leads:

• Inferior Leads: II, III, aVF

• Septal Leads: V1, V2
• Anterior Leads: V2, V3, V4
• Lateral Leads:
• 1. Lateral Precordial Leads: V4, V5, V6
• 2. High Lateral Leads: I, aVL
• Overlap in Lead V2 (septal and anterior)
• Overlap in Lead V4 (anterior and lateral)

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ECG Intervals – PR Interval

 Time from the onset of atrial depolarization (beginning of P wave)

until the onset of ventricular depolarization (beginning of QRS)
 In NSR, the PR interval must be between
o 0.12s and 0.20 sec and MUST be constant across the entire
strip
 Conduction during the first portion of the PR interval is rapid
because it occurs over specialized fibres in atrial tissue
 However, conduction slows down as the electrical impulse passes
through the AV node
 The delay is to allow the atria adequate time to contract and empty
their contents into the ventricles (called the “atrial kick”) prior to
the onset of ventricular systole
 The result is a major portion of the PR interval is taken up by the
time that the electrical impulse spends travelling through the AV
node

QRS Interval (Complex)

 The time it takes for ventricular depolarization

 Typically, it narrows because the electrical impulse is transmitted
quickly through the ventricles
 Heart rate dependent, usually up to 0.10 sec

QT Interval

 The beginning of ventricular depolarization (onset of QRS) until

the end of ventricular repolarization (end of T wave), therefore
roughly estimates the duration of an average ventricular action
potential
 HR dependent (approx. 0.2s – 0.4s)
 In practice, QT interval is expressed as a corrected Q-T (QTc).
This allows an assessment of the QT interval independent of HR
 QTc = QT interval (s)  square root of RR interval
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  Normal corrected QTc is less than 0.44 sec

QR, ST, RR Interval

ST Interval
 The end of S wave to the end of the T wave
 The initial phase of ventricular repolarization
QR Interval
 Also called VAT (ventricular activation time)
 Start of the QRS to the top of the R wave
 The time required for the impulse to go from the endocardium to
the epicardium of the heart
 0.02 seconds
RR Interval
 Distance between 2 consecutive R waves
 Ventricular cardiac cycle
 Used to measure heart rate

PR Segment:

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  The connecting horizontal line that extends from the end of the P
wave (atrial depolarization) to the onset of the QRS complex
(ventricular depolarization)
 Represents the end of depolarization of the atria
 Used as a baseline called the isopotential line or isoelectric line
 0.08 seconds
 When HR increases (exercise or tachycardia), PR segment shortens
and becomes less distinct
 ST segment deviations are based on the PR segment baseline

ST Segment

 The time between ventricular depolarization (end of QRS) and

repolarization (beginning of T wave)
 Start of ventricular repolarization
 0.14 seconds
 ST-Segment Elevation:
 Deviation of the ST segment above the PR segment baseline
 ST Segment Depression:
 Below the PR segment baseline
 Longer ST Segment: heart attack
 Shorter ST Segment: the heart isn’t receiving enough oxygen
(ischemia)

ST Segment and J point

• J Point represents the joining point of the last portion of the QRS
and the beginning of the ST segment
• The J Point is sometimes marked by a notch. The elevation of this
notch is referred to as J point elevation.
• ST Segment deviations are also described with respect to their
position relative to the
“J Point”

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ECG responses during and post-exercise
Rhythms that indicate the need to stop exercise immediately during
stress testing

 ventricular fibrillation (VF)

 sustained ventricular tachycardia (VT)
 bradycardia
 ST-segment elevation (≥1 mm)
 ST-segment depression (>2 mm of horizontal or downsloping ST-
segment depression)
 PVCs
 supraventricular tachycardia (SVT)
 bundle branch block
 Heart attack (MI)

PART 2 ECG

Calculating Heart Rate from the ECG printout

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1. Most Accurate Calculation
 The standard ECG paper speed is 25 mm/sec
 Therefore, HR (bpm) = 25 mm/s x 60 s/min
o mm/beat
 Simply, HR = 1500____
# of small boxes (between 2 consecutive beats, 2 R waves)
2. RULE of 300: Count the number of large squares between two R
waves and divide the total into 300 (since there are 5 small squares in
each large square) (not as accurate, esp with fast HR) (example: 300/1 =
300 bpm, 300/2 = 150, and so on)
Or memorize the following:
o 1 large square = 300 bpm Best when the R
waves are
o 2 large squares = 150 bpm exactly equal distance
o 3 large squares = 100 bpm on the lines
o 4 large squares = 75 bpm
o 5 large squares = 60 bpm
o 6 large squares = 50 bpm

3. Count the number of R waves in a 6-second strip and multiply by

10 (least accurate and requires a long time recorded on the ECG strip)
 1 large square = 0.20 seconds, therefore, 5 large squares = one
second
 A 6-second strip would require the # of R waves in 30 large
squares

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ECG Rate

Heart Rate
Bradycardia HR < 60 BPM
Tachycardia HR > 100 BPM
R-R Interval

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ST Elevation = Myocardial Infarction

 Anterior = ST elevation in leads V1-V4

 Lateral = ST elevation in leads I and avL
 Inferior = ST elevation in leads II, III, avF

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ECG Intervals – PR Interval

 Time from the onset of atrial depolarization (beginning of P wave)

until the onset of ventricular depolarization (beginning of QRS)
 In NSR, the PR interval must be:
 between 0.12s and 0.20 sec and
 constant across the entire strip
 A major portion of the PR interval is taken up by the time that the
electrical impulse spends travelling through the AV node

Abnormal PR Interval
 Shortening of the PR interval
 Less than 0.12 sec (3 small squares)
 Possible Interpretation: Pre-excitation
WPW – Wolff-Parkinson-White syndrome
 shortening of PR (< 0.12 s)
 widened QRS (> 0.12 s)
 delta wave (upstroke of the QRS)
 ST segment changes
 T wave changes

WPW Syndrome
 There is an accessory pathway (AP) that allows direct transmission
of the electrical impulse to the ventricles without having to first
pass through the AV node

 The PR interval is short (< 0.12 s) because the electrical impulse

bypasses the major time-consuming component of the PR interval
(which is the AV node)

 Patients with WPW are highly susceptible to cardiac arrhythmias

because the AP allows continued transmission of the impulse from
the atria to the ventricles

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PR Interval Lengthening

0.20 seconds
 Seen in disorders that prolong the process of conduction through
the AV node
 Acute occlusion of the right coronary artery tends to produce
ischemia of the AV node and adversely affects the conduction
capability of this structure because the right coronary artery
supplies blood to the AV node
Examples:
 acute inferior infarction (heart attack)
 first-degree AV block (impairment of the conduction between the
atria and ventricles)

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AV Blocks:
 1st degree AV block
 P-R interval is lengthened >0.2 s
 (5 squares)

WENCKEBACH 2 DEGREE AV BLOCK

 The p-R Interval gets longer and longer then resets.

QRS Interval (Complex) Review

The time it takes for ventricular depolarization

 Up to 0.10 seconds
 Conditions that may prolong QRS (ventricular activation, >
0.10s)
 Ventricular hypertrophy: because the electrical impulse needs
more time to get through a thickened myocardium
2. Defects in conduction:
 PVC’s
 bundle branch block
 damaged Purkinje fibres
 intraventricular conduction delay (IVCD)
 WPW Syndrome

PVCs
 PVCs: premature or “extra heartbeats”
 Interrupt the normal heart rhythm (felt as if the heart skipped a
beat, then beats fast (tachycardia, heart palpitations)
 impulses arise early in the cardiac cycle from the ventricles and are
forced to travel over non-specialized ventricular tissues,
depolarization takes place more slowly compared to following the
normal pathway)
 Often no P wave in front of QRS because the heartbeat originates
in the ventricles, not the atria
 Distorted QRS

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  Physical Activity: ventilatory threshold may be lower,
hyperventilation following exercise (because circulation is
inefficient)

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  Right Bundle Branch Block = Wide notch QRS in V1 and V2
 Left Bundle Branch Block = Notched in R in V5 and V6

QT Interval Review:

• The beginning of ventricular depolarization (onset of QRS) until

the end of ventricular repolarization (end of T wave), therefore
roughly estimates the duration of an average ventricular action
potential
• HR dependent (approx. 0.2s – 0.4s)
• In practice, QT interval is expressed as a corrected Q-T (QTc).
This allows an assessment of the QT interval independent of HR
• QTc = QT interval (s)  square root of RR interval
• Normal corrected QTc is less than 0.44 sec

QT Interval

Long QT interval:
 Electrolyte abnormalities
 antiarrhythmic drugs (prolong the process of repolarization)
 Dosing of these drugs is critical because prolonged repolarization
could predispose the patient to develop a potentially lethal
arrhythmia called torsades de pointes (the QRS intervals alternate
in a +ve and a –ve direction)
- Torsades de pointes
 may be induced by a premature ventricular beat occurring
early in the cardiac cycle and increases during bradycardia.
 may cause syncope
 Some cases can progress to ventricular fibrillation, which is
fatal unless treated promptly

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QT Interval

• Short QT interval:
• Drugs (Digitalis: ↑intracellular Ca which ↑ cardiac output by ↑
force of contraction)
• During exercise, Digitalis may produce ST segment depression
• Hypercalcemia
• Premature Atrial Contractions (PACs)

QT Interval – PACs

PACs (premature atrial contractions)

 When the rhythm is interrupted by an early beat arising somewhere
in the atria other than the SA node (premature P wave on ECG)
 Premature beats in the atria cause the SA node to be interrupted
 Conduction of the AV node may be blocked (impulse not
conducted to the ventricles). Distorted T waves on the ECG show
that the PAC is blocked.
 PACs may occur:
 singly
 in pairs
 every other beat (bigeminy).

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Points to consider when analyzing an ECG: Summary

• 1. Rate
• Use Rule of 300, find an R wave on a solid line. Is the HR
between 60 to 100 for NSR?
• 2. Rhythm
• Are the distances of the R waves similar?
• If the rhythm of the R waves (R-R) varies by 0.12 seconds (3
small squares), the rhythm is irregular
• 3. P waves
• Is there a P wave present for every QRS? All P waves should
be identical (or near identical) in size, shape, and position
• 4. PR interval
• Beginning of P wave to the beginning of the QRS

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 • Is it normal, between 0.12 – 0.20 seconds (3 to 5 small
squares, 5 small squares = 1 large square)
• Count the number of small squares and multiply by 0.04
seconds
• E.g. 4 squares x 0.04 = 0.16 seconds
• 5. QRS Interval
• The beginning of QRS to the end of QRS when the ST
segment begins
• Predominantly +ve in Lead II
• > 0.12 seconds is abnormal (possible BBB)
• > 0.12 seconds with no P wave (PVCs)

• When looking at the progression of waveforms

• Lead I
• +ve and the R wave amplitude is smaller than Lead II
• Lead II
• The R wave is taller than Lead I
• V1
• Looking at the right side of the heart and is mostly -ve
• V4, V5, or V6
• Depending on where the electrode is, should be the most +ve
chest lead (tallest R wave)

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