Electrocardiography

Dr. SARA SOOMRO

PG- Y2
Specific learning objectives

• Introduction

• History

• Normal ECG

• Procedure

• Limb Leads
ECG, EKG
It is the procedure of recording the electrical activity of the heart. The
electrode combination records the difference of potential difference at two
sites on the body. The potential differences are produced due to the electrical
activity of the heart.

Electrocardiograph is the machine

Electrocardiogram is the record

The characteristic shape and timing of the ECG waves are due to the spread
of wave of depolarization and repolarization associated with each heart beat.
• The ECG is not
only the oldest
but, in fact, over
100 years after
its introduction,
continues as the
most commonly
used
cardiovascular
laboratory
procedure.
What does the ECG look like?
 Waves
R

T
P

Q
S
Electrocardiogram waves

• P-wave – depolarization of atria

– Atria begin contracting about 25msec after the start of
the p-wave

• QRS-complex – ventricular depolarization

– Ventricles begin contracting shortly after the peak of
the R wave

• T-wave – ventricular repolarization

Electrocardiogram
intervals/segments
• Segments – extend from the end of one wave to
the start of another
• P-R interval: start of atrial depolarization to start
of QRS
• Q-T interval: time required for ventricles to
undergo a single cycle of depolarization and
repolarization; measured from end of P-R to end
of T
Remember

The representation of the electrical activity of the

heart is critically dependent on the
position of the electrodes. The same electrical
activity will look different on different electrode
combinations

A combination of electrodes for recording is called a LEAD

Leads that are routinely used for standard 12 lead ECG

Standard Limb Leads Wilhem Einthoven

Augmented Limb Leads E Goldberger

Precordial Leads Frank Wison

Correct Placement of leads
A look at an ECG complex
An ECG complex represents the electrical
events occurring in one cardiac cycle.

A complex consists of five waveforms

labeled with the letters P, Q, R, S, and T.

The middle three letters —Q, R, and S—are

referred to as a unit, the QRS complex.

ECG tracings represent the conduction of

electrical impulses from the atria to the
ventricles.
 The P wave
• It represents atrial depolarization—conduction of
an electrical impulse through the atria.
• . A normal P wave has the following
characteristics:
• location—precedes the QRS complex
• amplitude—2 to 3 mm high
• duration—0.06 to 0.12 second
• configuration—usually rounded and upright
• deflection—positive or upright in leads I, II, aVF,
and V2 to V6; usually positive but variable in
leads III and aVL; negative or inverted in lead
aVR; biphasic or variable in lead V1.
 Variations of the P-wave
• Tall, symmetrical, peaked waves seen in increased right
atrial pressure (P pulmonale)
• Notched/wide waves seen increased left atrial pressure
(P mitrale)
• Biphasic P waves can occur in both R & L atrial dilation.
Typically appear in leads V1 & V2
 The PR interval
• The PR interval tracks the atrial impulse from the
atria through the AV node, bundle of His, and
right and left bundle branches.
• . A normal PR interval has the following
characteristics
• location—from the beginning of the P wave to
the beginning of the QRS complex
• duration—0.12 to 0.20 second
 The short and long of it
• Short PR intervals indicate that the impulse
originated somewhere other than the SA node.
• This variation is associated with junctional
arrhythmias and preexcitation syndromes.
• Prolonged PR intervals may represent a
conduction delay through the atria or AV junction
due to digoxin toxicity or heart block
—slowing related to ischemia or conduction tissue
disease.
 The QRS complex
• Follows the P wave and represents
depolarization of the ventricles.
• Immediately after the ventricles depolarize, as
represented by the QRS complex, they contract.
• That contraction ejects blood from the ventricles
and pumps it through the arteries, creating a
pulse.
Ventricular Contraction
• Pay special attention to the duration and
configuration when evaluating a QRS complex. A
normal complex has the following
characteristics:
• Location—follows the PR interval
• Amplitude—5 to 30 mm high but differs for each
lead used
• Duration—0.06 to 0.10 second, or half of the PR
interval
• deflection—positive in leads I, II, III, aVL, aVF,
and V4 to V6 and negative in leads aVR and V1
to V3.
 The ST segment
• The ST segment represents the end of
ventricular conduction or depolarization
and the beginning of ventricular recovery
or repolarization.
• The point that marks the end of the QRS
com plex and the beginning of the ST
segment is known as the J point.
• Location—extends from the S wave to the
beginning of the T wave •
• Deflection—usually isoelectric (neither
positive nor negative); •
• may vary from –0.5 to +1 mm in some
precordial leads.
 Diagnostic ECG criteria for
STEMI

• When ST elevations reach threshold

values in two or m ore anatomically
contiguous leads, a diagnosis of STEMI
can be made.
• In men >40 years of age, ST-segment
elevation at the J point is ≥2 mm in
• leads V2 and V3

• >1 m m in all other leads. I n m en <40

years of age, threshold value for abnormal
ST-segment elevation at the J point in
leads V.
• In wom en, the threshold value of abnorm
al ST-segm ent elevation at the J point is
>1.5 m m in leads V2 and V3

• >1 m m in all other leads

 ST-segment depression

• An ST segment is considered depressed

• when it’s 0.5 mm or more below the base-
line. A depressed ST segment may
indicate myocardial ischemia or digoxin
toxicity.
 The T wave
• The T wave represents ventricular
recovery or repolarization.

• location—follows the S wave •

• amplitude—0.5 mm in leads I, II, and III
and up to 10 mm in the precordial leads
• configuration—typically round and smooth
• Deflection—usually upright in leads I, II,
and V3 to V6 inverted in lead aVR;
variable in all other leads.
• .
• Tall, peaked, or tented T waves indicate
myocardial injury or hyperkalemia.
Inverted T waves in leads I, II, or
V3through V6 may represent myocardial
ischemia. Heavily notched or pointed T
waves in an adult may mean pericarditis
 The QT interval
• The QT interval measures ventricular
depolarization and repo-larization.

• The length of the QT interval varies

according to heart rate.

• The faster the heart rate, the shorter the

QT interval
• location—extends from the beginning of
the QRS complex to the end of the T wave
• duration—varies according to age, sex,
and heart rate; usually •
• lasts from 0.36 to 0.44 second; shouldn’t
be greater than half the distance between
consecutive R waves when the rhythm is
regular.
 The importance of QT

•Interval increases the

risk of a life-
threatening
arrhythmia known as
Torsades de
pointes.
 The U wave
• The U wave represents the recovery
period of the Purkinje or ventricular
conduction fibers.
• location—follows the T wave •
• configuration—typically upright and
rounded •
• deflection—upright.
• The U wave may not appear on an ECG.
• A prominent U wave may be due to
hypercalcemia, hypokalemia, or digoxin
toxicity.
 8-step method

• Step 1: rhythm
• Paper and Pencil
 Step 2: Determine the rate
• Rapid estimation :

• Using the number of large boxes between

R waves or P waves as a guide, you can
rapidly estimate ventricular or atrial rates
by memorizing the sequence “300, 150,
100, 75, 60, 50.
• 1,500 method :

• Count the small squares between identical

points on two consecutive P waves
• and then divide 1,500 by that number to
get the atrial rate.
 Step 3: Evaluate the P wave
• Are P waves present? Do they all have
normal configurations? Do they all have a
• similar size and shape?
Step 4: Determine the duration of
the PR interval

• Now ask yourself: Is the duration a normal

0.12 to 0.20 second? Is the PR interval
constant?
Step 5: Determine the duration of
the QRS complex

• To calculate duration, count the number of

small squares between the beginning and
end of the QRS complex and multiply this
number by 0.04 second.
• Then ask yourself: Is the duration a normal
0.06 to 0.10 second?
 Step 6: Evaluate the T waves
• Ask yourself: Are T waves present? Do
they all have a normal shape?

• Do they all have a normal amplitude? Do

they all have the same amplitude?
Step 7: Determine the duration of
the QT interval

• Count the number of small squares

between the beginning of the QRS
complex and the end of the T wave, where
the T wave returns to the baseline.
(Normal 0.36 to 0.44 second?)