Toni Mustahsani Aprami Department Of Cardiology and Vascular Medicine, Padjadjaran University School of Medicine Hasan Sadikin Hospital

Bandung

LA RA (SAN) (HB) VV

(BB)

(AVN)

(BB) HB SAN AVN BB

RA

LA

Terms describing cardiac cycle

Systole
Activation

Diastole
Recovery Recovery

Electrical

Excitation

Depolarization
Shortening

Repolarization
Lengthening Relaxation Filling

Mechanical

Contraction Emptying

Cardiac Electrical Activity

Mechanical Actiyity

What medical problems can be diagnosed with an ECG?

Enlargement of cardiac chambers Hypertrophy of cardiac muscle

Cardiac arrhythmias
Insufficient coronary blood flow

Death of heart muscle and its location

Electrolyte abnormality

RECORDING ELECTRODES AND LEADS 1. Bipolar limb leads:

record the potential differences between two limbs

2. Unipolar precordial leads:

record the absolute electrical potential at each of designated torso sites

3. Augmented unipolar limb leads:

is designed to increase the amplitude of the output of limb leads

BIPOLAR LIMBS LEADS Lead I Lead II Lead III Left arm Left leg Left leg Positive input

AUGMENTED UNIPOLAR LIMBS LEADS

aVR
aVL aVF V1

Right arm
Left arm Left leg

Positive input

PRECORDIAL LEADS Right sternal margin, 4th intercostal space

V2
V3 V4 V5 V6

Left sternal margin, 4th intercostal space

Midway between V2 and V4 Left midclavicular line, 5th intercostal space Left anterior axillary line Left midaxillary line

Paper speed

25 mm/second 50 mm/second

Normal features of the electrocardiogram.

What does an ECG actually measure?

An ECG records voltage on its vertical axis against time on its horizontal axis
Measurement along the vertical axis indicates summation of the electrical activation of all of the cardiac cells Measurement along the horizontal axis indicates

heart rate, regularity, and the time intervals

required for electrical activity to move from one part of the heart to another

Systematic evaluation of the ECG

1. Rhythm
2. Rate and regularity 3. Axis 4. P-wave morphology 5. PR interval

6. QRS-complex morphology
7. ST-segment morphology

8. T-wave morphology
9. QTc interval

Q R R

QS

The normal cardiac rhythm:

The sinus rhythm

 The normal cardiac rhythm is called sinus rhythm because it is produced by electrical impulses formed within the SA node Sinus rhythm is essentially but not absolutely regular The P-wave axis of sinus rhythm is between 300 and 750 An abnormal P-wave axis is usually accompanied with an abnormally short PR interval. However, a short PR interval with in the presence of normal P-wave axis suggests an abnormal conduction pathway

Rate and regularity

 P waves and QRS complexes are used to determine cardiac rate and regularity Over a particular interval of time, normally, there are same numbers of P waves and QRS complexes Heart rate: * 1500 divided by number of small squares between successive P waves or QRS complexes * 300 divided by number of large squares between successive P waves or QRS complexes Normal heart rate: 60-100 beats per minute (bpm)

Axis of QRS Complex

 Normal axis: between 30 degrees and +90 degrees Right axis deviation (RAD): between +90 degrees and 180 degrees
Left axis deviation (LAD): between 30 degrees and 120 degrees

-1200

-90 0

-600

aVR -1500
1800 150 0

-300 aVL 00 300

1200

III

900

60 0

aVF

II

Negative in lead I Positive in lead aVF

Right axis deviation (RAD)

Positive in lead I Negative in lead aVF

Left axis deviation (LAD)

P-wave morphology

1. The contour: is normally smooth and monophasic (entirely positive or negative) in all leads except V1 or occasionally V2 2. Upright or positive P waves are normally seen in leads I, II, aVL, aVF, V4-V6 and downward in lead aVR. P wave in lead III may be either upright or downward. 3. P-wave duration is normally less than 0.12 seconds 4. The maximal amplitude is normally no more than 0.2 mv

Abnormal P waves

The PR interval

1. The PR interval measures the time required for an electrical impulse to travel from the atrial myocardium adjacent to the SA node to the ventricular myocardium adjacent to the fibers of the Purkinye network 2. The duration is normally from 0.11 to 0.20 seconds

3. PR interval varies with the heart rate. The faster the heart rate, the shorter the PR interval

Abnormal PR interval

Morphology of the QRS complex

1. Q waves
The presence of Q waves in leads V1, V2, and V3 should be consider abnormal. The absence of small Q waves in leads V5 and V6 should be consider abnormal

A Q wave of any size is normal in leads III and avR

In all other leads, a normal Q wave would be very small (less than 0.04 second and its voltage is less than 25% of the R-wave)

Abnormal Q waves

Abnormal Q waves

2. R waves
The positive R wave normally increases in amplitude and duration from lead V1 to V4 or V5. Loss of normal R-wave progression is considered abnormal

3. S wave
S wave should be large in V1 and then progressively smaller to V6

4. Ratio of R/S
Amplitude in V1 and V2 is normally less than 1. R in V5 or V6 + S in V1 or V2 is not more than 35 mm

Abnormal R wave in V1

5. Duration of the QRS complex (QRS interval)

It normally ranges from 0.07 second to 0.11 second (less than 0.12 second). The QRS interval has no lower limit that indicates

abnormality
6. Amplitude of QRS complex

There is no arbitrary upper limit for normal voltage of the QRS

complex. An abnormally low QRS complex when the amplitude

is no more than 0.5 mV in any limb leads and no more than 1.0
mV in any of the precordial leads

Abnormal QRS interval

0.19 s

Morphology of the ST

segment

1. The ST segment represents the period during which the ventricular myocardium remains in an activated or depolarized state 2. ST segment normally located at the same horizontal level with the PR segment 3. Normal variations: Slight upsloping, downsloping, or horizontal depresion Early repolarization : displacement of ST segment by as much as 0.1 mV in the direction of the ensuing T wave 4. ST segment may be altered when there is prolonged QRS complex

Normal ST segment

Normal ST-segment deviation

Morphology of the T and

U waves

The T wave
The T waves are positively directed in all leads except aVR (negative) and V1 (biphasic) T waves do not normally exceed 0.5 mV in any limb lead or

1.5 mV in any precordial lead

The U wave
U wave is either absent or present as a small wave following the T wave and is usually most prominent in leads V1 and V2. Increased prominence of the U wave indicates the possibility of hypokalemia

The QTc interval

1. The QT interval measures the duration of electrical activation and recovery of the ventricular myocardium 2. The QT interval decreases as the heart rate increases and therefore should be corrected for cardiac rate (QTc interval) 3. QTc= QT/RR interval (in seconds) The upper limit of QTc is 0.46 second (slightly longer in females) 4. QT interval varies among different leads. The longest QT interval measured in multiple leads should therefore be considered the true QT interval

Thank You

Excitation of the Heart

Excitation of the Heart

What is an Electrocardiogram ?
An ECG is the recording (gram) of the

electrical activity (electro) of the cells of the

heart (cardio) that reaches the body surface

Initiates the heart muscle to contract, to pump blood to the tissues

+ + + + + + + + + + + + + + + +
Depolarizing cell

Resting cells

+ + + + + + +

+ + + + + + + +

Depolarized cells

+ + + + + + + + + + + +

Depolarized cells

+ + + + + + + + + + + +
Repolarizing cell

+ + +

+ + + + + + + + + +
Repolarized cells

+ + + + + + + + + + + + + + + +

+ + +

+ +

+ +

+ +

+ + +