THE Electrocardiogram (ECG)

THE
ELECTROCARDIOGRAM
(ECG)
by
ASSOC. PROF. DR. MAUNG MAUNG CHO

Dept of Basic Medical Sciences, Kulliyyah of Medicine
International Islamic University Malaysia,
Kuantan, Pahang
THE ELECTROCARDIOGRAM (ECG)
The spread of action potential from the Sinoatrial node (S.A. Node) to the
artria, then down the Atrioventricular bundle (AV bundle and finally to the
ventricle is associated with electrical potential fluctuations which can be
recorded at distances remote from the heart (i.e. from the body surface).
This is possible because body fluid contains electrolytes and therefore are
good conductors. [The body is a volume conductor].
ECG RECORDING
Recording Electrodes (Leads)
[A] Bipolar leads
These record the potential difference between (two) active
electrodes.
A1. Standard Limb Leads
Lead (+)ve electrode (-)ve electrode
I Left arm (LA) Rt. Arm (RA) = LA-RA
II Left foot (LF) Rt. Arm (RA) = LF-RA
III Left foot (LF) Lt. Arm (LA) – LF-LA
[A] Unipolar leads
These have an active (exploring) electrode placed or a chosen site
linked with an indifferent electrode. One being zero, the potential
difference between the two represents the actual local potential. They are
called “V” leads because they record values approaching meaningful
voltages.
B1. Unipolar limb leads
aVR, aVL, aVF (a = augmented; when the amplitude of
deflection increased. These are recordings between one limb and the other
two limbs).
B2. Unipolar chest leads (Precordial leads)
V1 = 4th intercostal space (ICS), right sternal border.
V2 = “ , left “
V3 = equidistance between V2 and V4
V4 = 5th ICS, midclavicular line Apex leads
V5 = 5 th ICS, anterior axillary line
V6 = 5th ICS, midaxillary line
[ * Usual ECG consist of (12) leads : I, II, III
aVR, aVL, aVF
V1  V6 ]
aVR aVL
R V1
1.0 V2
V3
Isoelectric
line
V4 V5 V6
0.5
PR Segment ST Segment
P T
0
PR interval Q
-0.5 S
QRS duration
QT interval
aVF
0 0.2 0.4 0.6 Unipolar
TIME (s) electrocardiographic leads
Waves of the ECG
I
V1 V2
aVR aVL
V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
III
II aVF
P Wave
- represents atrial depolarization
It begins as the impulse spread from the SA node across the atria. The activity
of the SA node itself cannot be detected in the ECG. The duration (0.1 sec.)
indicates the time taken for the impulse to spread throughout the atrial muscle.
Because the impulse spread from right to left and downward, the P wave is:
 Upright in leads I, II and aVF
 Inverted in aVR
 Inverted in leads III, aVL and V1
* The magnitude of P wave is some guide to the functions activity of atria.
PR Interval
- measured from onset of P wave to the beginning of QRS complex
It measures the AV conduction time which includes

 AV nodal delay
 Conduction down the bundle of His to the ventricular myocardium.
Duration 0.12 – 0.20 seconds (normal adults with normal heart rate)
QRS Complex
- represents ventricular depolarization
The “Q” wave is a downward deflection preceeding an R wave

which is an upward deflection of the QRS; the S wave is a
downwarddeflection following an R wave.
(In the routine 12 leads ECG, the manifestation of atrial

repolarization is submerged in the QRS complex).
QRS duration; the upper limit of normal is 0.10 second.

ST Segment and T Wave
- represents ventricular repolarization
ST segment is the part between the end of QRS complex and

the beginning of T wave.
T wave is normally in the same direction as the largest part of

the QRS complex .
Derivation from normal are commonly associated with

myocardial ischaemic e.g. * the hall mark of myocardial
ischaemial infarction is ST segment elevation in leads
overlying the area of infarction. At a later stage, ST segment
elevation less pronounced as T wave inversion developed.
USES OF ECG
- Detection of heart rate (both atrial and ventricular)
- Rhythm (regular or irregular). Diagnosis of arrhythmias.
- Conduction of cardiac impulse (delayed or block; site of
defect)
- Change in myocardial perfusion (ischaemic);
structure (infarction, hypertrophy);
function (ventricular fibrilation or cardiac arrest)
- Change in plasma electrolytes (K+ , Ca+)
e.g. Blood K+   T wave decrease
[Heart block, atrial extrosystoli, atrial tachycardiac, atrial

flutation, atrial fibrilation, myocardial infarct]

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THE

ASSOC. PROF. DR. MAUNG MAUNG CHO

It measures the AV conduction time which includes

- represents ventricular depolarization

The “Q” wave is a downward deflection preceeding an R wave

(In the routine 12 leads ECG, the manifestation of atrial

QRS duration; the upper limit of normal is 0.10 second.

ST segment is the part between the end of QRS complex and

T wave is normally in the same direction as the largest part of

Derivation from normal are commonly associated with

[Heart block, atrial extrosystoli, atrial tachycardiac, atrial

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