ELECTROCARDIOGRAM

Electrocardiogram
Human body is a volume conductor, i.e. body fluids
are good conductor of electricity as it contains
large amounts of electrolytes. Therefore
electrical changes occurring in heart with each
heart beat are conducted all over the body and can
be picked up from the body surface.

The record of these electrical fluctuations during

cardiac cycle is called as Electrocardiogram or
ECG.

The instrument used to record an ECG is called as

Electrocardiograph and the technique is called as
Electrocardiography.
 Recording Conventions
ECG is recorded on a mm square graph paper, moving at a speed of
25mm/sec.

X – axis represents time, therefore 1mm = 0.04sec.

Y – axis represents voltage, therefore 1mm = 0.1mV.

Any deflection of record above the baseline is regarded as

positive deflection. It occurs when active electrode becomes
positive relative to indifferent electrode and denotes spread
of excitation wave i.e. depolarization wave towards the
electrode.

Any deflection of record below baseline is regarded as negative

deflection. It occurs when active electrode becomes negative
relative to indifferent electrode and denotes spread of
excitation wave i.e. depolarization wave away from the electrode.

No deflection from baseline means isoelectric line or

isoelectric segment.
 Waves of ECG
P, Q, R, S, T, U.

P - wave :
•Duration – 0.1 sec, directed upwards and rounded/pointed.
•It is due to atrial depolarization and represents spread of impulse
from SA node to atrial muscles.
•Peaks corresponding with invasion of AV node.
•Height is 0.5mV, represents functional activity of atrial muscles.
•
PR segment :
•Following P-wave there is brief isoelectric period of 0.04 sec.

QRS complex :
•Due to ventricular depolarization.
•Completed just before opening of semilunar valve.
•Atrial repolarisation activity merges with QRS complex.
•
Q wave :
•Small negative deflection of height less than 0.2mV and duration less
than 0.04s.
•Beginning of Q-wave represents the invasion of mid-portion of IV septum.
R - wave :
•Prominent positive wave.
•Upstroke coincide with onset of ventricular systole.
•Represents excitation process suddenly invading both ventricles i.e.
interventricular septum and larger part of both ventricles.
•Height is directly proportional to functional activity of ventricles.
•
S - wave :
•Negative deflection which follows R-wave.
•Represents excitation of more basal parts of ventricles.
•
Duration of QRS complex 0.08 to 0.12 sec and height of 1.5-2 mV.

ST segment :
•Isoelectric period from end of S-wave and beginning of T-wave.
•Duration 0.04-0.08 sec.
•
T - wave :
•Rounded positive deflection of duration of 0.27 sec and 0.5 mV in height.
•Represents ventricular repolarisation.
•End of T-wave coincides with closure of semilunar valves.
Isoelectric period :
•Following T-wave small isoelectric period – 0.04 sec.

U - wave :
•Rarely seen, positive, small, round wave.
•0.08 sec in duration and 0.2 mV in height.
•Due to slow repolarization of papillary muscles.
•
PR Interval :
•
•Interval from beginning of P-wave till beginning of Q/R wave.
•Represents atrial depolarization and conduction time of Bundle of His.
•Normal duration 0.13 - 0.16 sec.
•
QT interval :
•Interval from beginning of Q and end of T-wave.
•Duration 0.4 sec.
•Represents ventricular depolarization and repolarization.
ST interval :
•
•End of S wave to end of T wave.
•Normally 0.32 sec.
•Represents ventricular repolarization.
•
J point :
•
•Point between S wave and ST segment.
•Point of no electrical activity.
•
 Procedure of recording ECG
Two methods are employed :
1.Unipolar method in which ECG is recorded using one active electrode.
2.Bipolar recording in which ECG is recorded using two active electrodes.

Unipolar Method :
In a volume conductor, the sum of potentials at ends of an
equilateral triangle with current source at its centre is zero at all
times. A similar triangle can be approximated in our body by placing
electrodes at RA, LA and LF, where heart in centre acts as current
source

1 . Precordial leads of Wilson :

V1 – 4th intercostal space to right of sternum
V2 – 4th intercostal space to left of sternum
V3 – midway between V2 and V4
V4 – 5th intercostal space in mid-clavicular line
V5 – 5th intercostal space in anterior axillary line
V6 – 5th intercostal space in mid-axillary line

1.
2 . Unipolar limb leads :
VL – left arm
VF – left foot
VR – right arm

Characteristics :
1.V1 and V2 reflect right ventricular activity and QRS deflection is
negative
2.V3 and V4 reflect activity of both ventricles at interventricular septum
activity and is biphasic
3.V5 and V6 reflect left ventricular activity mainly and is positive
P-wave is always positive as wave travels from SA node
(posteriorly) to AV node (anteriorly)
T wave mailnly follows main direction of QRS complex

1.VF reflects activity of inferior surface of heart formed by both

ventricles – biphasic QRS complex
2.VL reflects electrical activity of left outer surface of heart –
predominantly positive QRS complex
3.VR reflects electrical activity of cavity of ventricles thus all waves P
QRS and T waves are all negative
7.
Augmented limb leads :
These are unipolar leads with slight modification in recording technique.

One limb is connected to positive terminal of ECG and other 2 limbs connected
through electrical resistance to negative of ECG machine.

This arrangement increases size of potentials by 50% without any change in

configuration

Vector of augmented limb leads = 3/2 vector of unaugmented limb lead

These are aVL, aVF, aVR.

Bipolar Recording :
ECG is recorded using two active electrodes therefore the deflection
recorded here at any movement represents algebraic sum of two
constituent limb leads.

Bipolar leads are:

Lead I : Records difference in potentials between RA and LA (LA positive)

and QRS similar as aVL.
Lead II : Records difference in potentials between RA and LF (LF
positive) and QRS deflection same as aVF.
Lead III : records difference in potentials between LA and LF (LF
positive) and QRS is similar to aVF.

Eithoven ’ s Law :
Lead II = Lead I + Lead III
= (VL-VR) + (VF-VL)
= VF-VR
 Importance of 12 Lead
ECG

It is necessary to have 12 lead ECG because

leads I, II and III, aVL, aVF and aVR reflects
depolarization of heart from frontal plane
and V1 to V6, reflect electrical activation
of heart from horizontal plane. Thus, it
gives a 2D picture of 3D electrical
activity of myocardium.
STRESS
TEST
 Stress Testing
A cardiac stress test is a medical test that indirectly reflects arterial
blood flow to the heart during physical exercise. When compared to blood flow
during rest, the test reflects imbalances of blood flow to the heart's left
ventricular muscle tissue – the part of the heart that performs the greatest
amount of work pumping blood.

Procedure :
The patient either walks on a treadmill or is given an intravenous(IV)
medication that simulates exercise while connected to an electrocardiogram(ECG)
machine used to record a 12-lead ECG.

The level of exercise is increased in 3-minute stages of progressively

increased grade (% incline) and speed (mph, km/h, etc). The patient's symptoms
and blood pressure response are repeatedly checked.

Some patients with abnormal resting ECGs or those who are unable to walk
safely can be "exercised" pharmacologically instead of by walking on a
treadmill. The patient will typically receive a pharmaceutical such as
dipyridamole or adenosine or dobutamine (which stimulates heart rate and
pumping force) while a cardiologist or physician assistant reviews the ECG
tracing and checks blood pressure periodically.
Bruce Protocol :
A protocol for exercise stress testing of cardiac patients developed by Robert
A. Bruce.
Before the development of the Bruce Protocol there was no safe, standardized
protocol that could be used to monitor cardiac function in exercising
patients.

Stage Min % MPH METS

1 3 10 1.7 4.7
2 6 12 2.5 7
3 9 14 3.4 10.1
4 12 16 4.2 12.9
5 15 18 5 15
How does a Regular Stress Test
Work?

Patients with coronary artery blockages may have minimal

symptoms and an unremarkable or unchanged ECG while at
rest. However, symptoms and signs of heart disease may
become unmasked by exposing the heart to the stress of
exercise. During exercise, healthy coronary arteries dilate
more than an artery that has a blockage. This unequal
dilation causes more blood to be delivered to heart muscle
supplied by the normal artery. In contrast, narrowed
arteries end up supplying reduced flow to it's area of
distribution. This reduced flow causes the involved muscle
to "starve" during exercise. The "starvation" may produce
symptoms (like chest discomfort or inappropriate shortness
of breath), and the ECG may produce characteristic
abnormalities.
 When is a Regular Stress Test
ordered?
ØPatients with symptoms or signs that are suggestive of
coronary artery diseases (CAD).
Ø
ØPatients with significant risk factors for CAD.
Ø
ØTo evaluate exercise tolerance when patients have
unexplained fatigue and shortness of breath.
Ø
ØTo evaluate blood pressure response to exercise in
patients with borderline hypertension.
Ø
ØTo look for exercise-induced serious irregular heart
beats.
Ø
 What is the reliability of a Regular
Stress Test?

If a patient is able to achieve the target heart rate, a

regular treadmill stress test is capable of diagnosing
important disease in approximately 67% of patients with
coronary artery disease. The accuracy is lower (about 50%)
when patients have narrowing in a single coronary artery
or higher (greater than 80%) when all three major arteries
are involved.

Approximately 10% of patients may have a "false-positive"

test (when the result is falsely abnormal in a patient
without coronary artery disease).
Contraindications:
•
ØAcute myocardial infarction within 48 hrs
ØUnstable angina not yet stabilized with medical therapy
ØUncontrolled arrhythmia
ØSymptomatic severe aortic stenosis
ØAortic dissection
ØPulmonary embolism
ØPericarditis
•
•

Risks:
ØPalpitation
ØChest pain
ØShortness of breath
ØHeadache
ØNausea
ØFatigue
ØAdenosine and dipyridamole can cause mild drug-induced hypotension.
Ø
Limitations:
Ø
ØStress tests do not detect atheroma or
vulnerable plaque.
Ø
ØIt requires high-grade stenosis to indicate heart
attack risk.
Ø
ØLike all tests, stress testing has problems with
both falsely positive and falsely negative
results.