Electrocardiogram

Definition and Uses of ECG

An electrocardiogram (ECG) is a graphic record of the electrical activities of the heart, obtained
by placing electrodes on the body surface to record voltage differences generated by the heart.
Electrocardiography is the method of recording ECG, and an electrocardiograph is the machine
used.

Uses of ECG:

Assessing anatomical orientation of the heart.

Estimating the relative size of heart chambers.
Diagnosing disturbances in heart rhythm and conduction.
Detecting myocardial ischemia.
Determining the location, extent, and progression of myocardial infarction.
Evaluating the effects of altered electrolyte concentrations.
Assessing the influence of certain drugs (e.g., digitalis).
Monitoring the efficiency of electronic pacemaker function.

ECG Leads
An ECG lead is a pair of electrodes used to detect potential differences in the heart. Leads are
classified as direct (used during surgery) or indirect (applied to the body surface). Indirect leads
include limb leads, chest leads, and esophageal leads. A standard 12-lead ECG uses leads
positioned in both the frontal and transverse planes.

Limb Leads

Limb leads lie in the frontal plane and are either bipolar or unipolar.

Bipolar Limb Leads:

Record the potential difference between two electrodes.
Lead I: Right arm (negative) to Left arm (positive).
Lead II: Right arm (negative) to Left leg (positive).
Lead III: Left arm (negative) to Left leg (positive).
Einthoven's Triangle: An equilateral triangle formed by Leads I, II, and III, with the heart at
its center.

Unipolar Limb Leads (Augmented Leads):

Use an exploring electrode and an indifferent electrode (connected to other limbs via high
resistance). The term "augmented" refers to the amplification of the signal.
aVR: Right arm (positive) to Left arm + Left leg (negative).
aVL: Left arm (positive) to Right arm + Left leg (negative).
aVF: Left leg (positive) to Right arm + Left arm (negative).
Chest Leads (Precordial Leads)

Chest leads lie in the transverse plane and are typically unipolar. They use an exploring electrode
on the chest and an indifferent electrode connected to the limbs via Wilson's terminal
(maintained at zero potential).

V1: Right fourth intercostal space, right sternal border.

V2: Left fourth intercostal space, left sternal border.
V3: Midpoint between V2 and V4.
V4: Left fifth intercostal space, midclavicular line.
V5: Left fifth intercostal space, anterior axillary line.
V6: Left fifth intercostal space, midaxillary line.

Additional chest leads (V7-V9) can be used for specific views.

Esophageal Leads

Esophageal leads use an electrode positioned in the esophagus close to the heart. They are
designated by distance from incisor teeth (e.g., E15-25 for right atrium activity, E40-50 for
posterior left ventricle).

Normal ECG Waves, Segments, and Intervals

The ECG tracing displays various waveforms that represent electrical events during the cardiac
cycle.

ECG Waves
P Wave: First positive deflection; represents atrial depolarization.
QRS Complex: Consists of Q, R, and S waves; represents ventricular depolarization.
Q Wave: Initial negative deflection.
R Wave: Positive deflection.
S Wave: Second negative deflection.
T Wave: Positive deflection; represents ventricular repolarization.
U Wave: Final positive deflection (not always present); due to slow repolarization of papillary
muscles.

ECG Segments

Segments are typically isoelectric (baseline) periods.

PR Segment: Between the end of the P wave and the beginning of the QRS complex.
ST Segment: Between the end of the QRS complex and the beginning of the T wave. The J
point is where the QRS complex ends and the ST segment begins.
ECG Intervals

Intervals include waves and segments.

PR Interval: From the beginning of the P wave to the beginning of the QRS complex.
Normal duration: 0.12 to 0.20 seconds.
Significance: Atrial depolarization and conduction through the AV node.
QRS Interval (QRS Duration): Duration of the QRS complex.
Normal duration: 0.08 to 0.10 seconds.
Significance: Ventricular depolarization (and atrial repolarization).
QT Interval: From the beginning of the QRS complex to the end of the T wave.
Normal duration: 0.40 to 0.43 seconds.
Significance: Ventricular depolarization and repolarization (electrical systole).
ST Interval: From the J point to the end of the T wave.
Normal duration: Approximately 0.32 seconds.
Significance: Ventricular repolarization.
PP Interval: Between successive P waves; used to calculate atrial rate.
RR Interval: Between successive R waves; used to calculate heart rate (ventricular rate).

Physiological Basis of ECG

The body acts as a volume conductor, allowing electrical activity from the heart to be detected
on the surface. ECG records voltage differences generated by the heart's electrical activity, which
can be understood using the concept of a dipole.

Concept of a Dipole

A dipole consists of two poles (positive and negative) with equal and opposite charges. In a
volume conductor, a dipole creates a voltage field that can be measured by electrodes. The
recorded voltage depends on the magnitude and direction of the dipole relative to the electrodes.

Heart as a Dipole

Cardiac muscle cells have a resting potential (negative inside, positive outside). During
depolarization, the inside becomes positive, creating a dipole. The region of myocardium that is
depolarized forms the negative pole, and the region yet to be depolarized forms the positive pole.
As excitation spreads, the dipole shifts. The ECG records the net dipole, which is the algebraic
sum of all individual dipoles at any given moment.

Origin of ECG Waveforms

The shape and direction of ECG waves are determined by the magnitude and direction of the net
cardiac dipole relative to the recording lead's electrodes.

P Wave: Atrial depolarization; upward deflection in Lead II because the net dipole is directed
towards the positive electrode (left leg).
QRS Complex: Ventricular depolarization.
Q Wave: Initial septal depolarization (left to right); dipole directed away from the positive
electrode in Lead II, causing a negative deflection.
R Wave: Depolarization of the main ventricular mass (especially the left ventricle); dipole
directed towards the positive electrode in Lead II, causing a large positive deflection.
S Wave: Depolarization of the last parts of the ventricles; dipole directed away from the
positive electrode in Lead II, causing a negative deflection.
ST Segment: Isoelectric; represents the period after ventricular depolarization and before
repolarization begins.
T Wave: Ventricular repolarization. Although repolarization is opposite to depolarization, the T
wave is typically upright in Lead II because repolarization occurs from epicardium to
endocardium, creating a dipole in the same general direction as depolarization.

Cardiac Dipoles as Vectors

The net cardiac dipole can be represented as a vector, indicating both magnitude and direction.
The 12-lead ECG provides information about this vector in both the frontal and transverse planes.

Frontal Plane: Represented by limb leads (bipolar and unipolar). The hexaxial reference
system organizes these leads at 30° intervals.
Transverse Plane: Represented by chest leads.

Systemic Interpretation of ECG

A systematic approach to ECG interpretation is crucial.

1. Heart Rate: Calculate atrial and ventricular rates.

Normal rate: 60-100 beats/min.
Bradycardia: < 60 beats/min.
Tachycardia: > 100 beats/min.
2. Rhythm: Assess regularity (regular or irregular).
3. Mean Cardiac Vector (Axis): Determine the average direction of ventricular depolarization.
4. P Waves: Assess morphology, duration, and relationship to QRS complexes.
5. PR Interval: Measure duration.
6. QRS Complex: Measure duration, amplitude, and configuration. Look for pathological Q waves.
7. ST Segment: Assess for elevation or depression.
8. T Waves: Assess morphology.
9. QT Interval: Measure duration and calculate corrected QT (QTc).

Heart Rate Calculation

Regular Rhythm: Ventricular rate = 1500 / (number of small squares between two R waves).
Irregular Rhythm: Count QRS complexes in a 6-second strip (approx. 150 large squares or
750 small squares) and multiply by 10.
Mean QRS Axis

The mean QRS axis represents the average direction of ventricular depolarization.

Normal Value: -30° to +110°.

Left Axis Deviation (LAD): Axis < -30°.
Right Axis Deviation (RAD): Axis > +110°.

Rough Estimation using Leads I and aVF:

Normal: QRS predominantly upright in both I and aVF.

LAD: QRS predominantly upright in I, predominantly negative in aVF.
RAD: QRS predominantly negative in I, predominantly upright in aVF.

Common Causes of Axis Deviations:

LAD: Left ventricular hypertrophy, left anterior hemiblock, inferior myocardial infarction.
RAD: Right ventricular hypertrophy, left posterior hemiblock.

Abnormal ECG Findings

Cardiac Arrhythmias

Disorders of the heart's rhythm.

Bradyarrhythmias: Slow heart rate (< 60 bpm).

Sinus Bradycardia: Slowing of the SA node.
Heart Blocks: Impaired conduction from atria to ventricles.
Tachyarrhythmias: Fast heart rate (> 100 bpm).
Sinus Tachycardia: Increased rate from the SA node.
Supraventricular Tachycardias (SVT): Originating above the ventricles (e.g., atrial
tachycardia, AV nodal reentrant tachycardia).
Ventricular Tachycardias (VT): Originating in the ventricles.

Specific Arrhythmias:

Sinus Arrhythmia: Variation in heart rate with respiration (normal physiological phenomenon).
Sick Sinus Syndrome: Disease of the SA node causing abnormal rates and rhythms.
Atrial Premature Beats: Early beats originating from ectopic atrial foci.
Paroxysmal Supraventricular Tachycardia (PSVT): Episodes of rapid heart rate originating
above the ventricles.
Nodal PST: Often due to AV nodal reentry.
Atrial PST: Regular discharge from an atrial focus.
Atrial Flutter: Rapid, regular atrial activity (flutter waves, "sawtooth" pattern) with variable AV
block.
Atrial Fibrillation: Disorganized atrial activity (fibrillatory waves) with an irregularly irregular
ventricular rhythm.
Ventricular Extrasystole: Premature beats originating from ectopic ventricular foci (wide
 QRS).
Paroxysmal Ventricular Tachycardia (PVT): Episodes of rapid ventricular rhythm; more
serious than SVT.
Ventricular Fibrillation: Chaotic electrical activity in the ventricles, leading to ineffective
pumping and cardiac arrest.

Conduction Disorders (Heart Blocks)

Impairment of electrical impulse conduction.

First-Degree AV Block: Prolonged PR interval ( > 0.20 s) with all impulses conducted.
Second-Degree AV Block: Some atrial impulses fail to conduct to the ventricles.
Mobitz Type I (Wenckebach): Progressive PR prolongation until a beat is dropped.
Mobitz Type II: Intermittent failure of conduction, often with a constant PR interval for
conducted beats.
Third-Degree (Complete) Heart Block: Complete interruption of conduction between atria and
ventricles; atria and ventricles beat independently. P waves and QRS complexes are
dissociated.
Bundle Branch Block (BBB): Block in the right or left bundle branch, causing widening of the
QRS complex.
Right Bundle Branch Block (RBBB): Characteristic changes in right precordial leads (V1-
V3).
Left Bundle Branch Block (LBBB): Characteristic changes in left precordial leads (V5-V6)
and left limb leads.

Acceleration of Conduction
Wolff-Parkinson-White (WPW) Syndrome: Presence of an accessory pathway (Bundle of
Kent) leading to pre-excitation. Characterized by a short PR interval, wide QRS complex with a
slurred upstroke (delta wave), and a normal PJ interval.
Lown-Ganong-Levine (LGL) Syndrome: Impulses bypass the AV node via an accessory
pathway, resulting in a short PR interval with a normal QRS complex.

Myocardial Abnormalities
Myocardial Ischemia: Reduced blood supply. Can cause T wave inversion and ST segment
depression.
Myocardial Infarction (MI): Acute tissue death due to lack of blood supply.
Acute MI: ST segment elevation in leads overlying the infarct, ST depression in reciprocal
leads. Pathological Q waves may develop later.
Chronic MI: Scar tissue formation, often with persistent pathological Q waves.

Ventricular Hypertrophy

Enlargement of ventricular muscle mass.

Left Ventricular Hypertrophy (LVH): Increased QRS voltage in left precordial leads (V5, V6)
and limb leads (I, aVL); often associated with LAD.
Right Ventricular Hypertrophy (RVH): Increased QRS voltage in right precordial leads (V1, V2);
 often associated with RAD.

Electrolyte Disturbances

Alterations in plasma electrolyte concentrations significantly impact ECG findings.

Hyperkalemia (High Potassium):

Mild: Peaked T waves.
Moderate: Widening of QRS, prolonged PR, flattened T waves.
Severe: Sine wave pattern, ventricular arrhythmias, cardiac arrest.
Hypokalemia (Low Potassium):
ST segment depression, flattened T waves, prominent U waves.
Severe: Prolonged PR, T wave inversion, arrhythmias.
Hypercalcemia (High Calcium): Shortened QT interval.
Hypocalcemia (Low Calcium): Prolonged QT interval.
Hypernatremia (High Sodium): Usually normal ECG, or high-voltage complexes.
Hyponatremia (Low Sodium): Low-voltage complexes.

His Bundle Electrogram (HBE)

HBE records the electrical activity of the His bundle, providing detailed information about
conduction through the AV node and His-Purkinje system.

Deflections:
A: AV node activation.
H: His bundle activation.
V: Ventricular depolarization.
Intervals:
PA Interval: SA node to AV node (27 ms).
AH Interval: Conduction through AV node (92 ms).
HV Interval: Conduction through His bundle and branches (43 ms).

These intervals help diagnose conduction abnormalities, especially in differentiating

supraventricular from ventricular arrhythmias and assessing the severity of heart blocks.