What is Electrocardiography?

Electrocardiography is the branch of cardiology, which involves the study

of electrical activity in the heart by an instrument known as an
electrocardiograph.
Know the terms:
The electrocardiogram is
derived from three words
electro, cardio, and gram
• Electro means electrical
activity
• Cardio means heart
• Gram means recording
What is an Electrocardiogram?
• Electrocardiogram (ECG or EKG) is the recording of the electrical activity
produced by the cells of the heart throughout the cardiac cycle.
• This electrical activity causes rhythmic contraction of the heart and
pumping of blood to different parts of the body. The electrodes placed on a
subject's skin picks up the electrical activity moving along each cell,
within the heart. The patterns of the electrical activity are then recorded on
a special calibrated paper with the help of a pointer.
Why an ECG is Performed for a Patient?
• To check the electrical activity of the heart
• To find the etiology of unexplained chest pain or cardiovascular diseases
in the patient
• To find the cause of symptoms such as irregular heartbeats, dizziness,
and shortness of breath in the patient
• To check if the patient has atrial or ventricular hypertrophy
• To check the performance of mechanical devices such as pacemakers in
the heart
• To check the functioning of the heart in patients with high blood
pressure, high cholesterol level, diabetes, or family history of cardiac
diseases
• To check the functioning of the heart in patients who have a habit of
smoking or alcohol consumption
Before learning more about the ECG and patterns of electrical activity, let
us quickly recap the anatomy and the conducting system of the heart.
Conducting System of the Heart
The conduction system of the heart consists of:
• Sinoatrial node (SA node)
• Interatrial conduction fibers or Bachmann's bundle
• Atrioventricular node (AV node)
• Bundle of His
• Purkinje network (conduction pathways)
• Right and left Bundle branches
The left bundle branch divides into the anterosuperior and posteroinferior fascicles
before ramification into the Purkinje network.
Sinoatrial node (SA node)
 The sinoatrial (SA) node is located in the upper posterior wall of the
right atrium. It acts as a natural pacemaker of the heart. It generates an
electrical signal or cardiac impulse at regular intervals (60 to 100
times/minute). Each impulse produced by the SA node rapidly spreads
through both atria along the interatrial conducting fibers (Bachmann's
bundle) and causes atrial depolarization.
 Atrial depolarization causes contraction of the atrial muscles and allows
the rapid flow of blood from the atria to the ventricles.
 Once the atria become empty, the valves between the atria and ventricles
close, and the atria begin to refill. At this point, the cardiac impulse
reaches the AV node and then passes through the Bundle of His, the
Bundle branches, and Purkinje fibers.
Atrioventricular node (AV node)
The atrioventricular (AV node) is located on the floor of the right atrium,
near the interatrial septum. It acts as the path for the cardiac impulse to
travel from the atria conducting fibers to the ventricular bundle of His.

The AV node consists of three regions the upper, middle, and lower
portion.
• The upper portion is called the atrionodal (AN) region. It connects the
atria to the middle portion of the AV node.
• The middle portion is called the nodal (N) region. It is primarily
responsible for delaying the AV conduction. The slowing of the cardiac
impulse delays ventricular activation and provides enough time to the
contracting atria to pump all the blood into the ventricles. Acetylcholine
is released at this site. It decreases the pacemaker rate by increasing
potassium ions movement and decreasing calcium and sodium
movement across the membranes of the heart cells.
• The lower portion is called nodo-His (NH) region. It is connected to
the bundle of His.
Bundle of His, the Bundle branches, and
Purkinje fibers:
• The cardiac impulse enters the bundle of His from the AV node. The
bundle of His is located in the interventricular septum and divides into
right and left bundle branches. These branches extend as the long
fibers called Purkinje fibers, which are distributed throughout the
ventricular myocardium.

• The Purkinje fibers conduct the cardiac impulse very rapidly

throughout the ventricles causing them to contract. At this point, the
ventricles become empty, the atria are full, and the valves between
them are closed. The SA node is ready to release another cardiac
impulse and the complete cardiac cycle repeats.
Principles of ECG
• ECG records the electrical potentials that travel through the
myocardium.
• A standard 12-lead ECG provides spatial information about the heart's
electrical activity in three orthogonal directions:
right ↔ left,
superior ↔ inferior,
anterior ↔ posterior.
• The rhythm strip is usually recorded from lead 2 and placed at the
bottom of the 12-lead ECG. A calibration notch is usually placed in all
ECGs to denote 1 millivolt (mV).
• A 1-millivolt of electrical activity causes a 10 mm deflection vertically.
• The speed of ECG is usually 25 mm/second. Each 25 mm length is 1
second, 5 mm is 0.2 seconds, and 1 mm is 0.04 seconds.
• The sensitivity of the ECG in terms of mV/10 mm or speed may be changed
if there is a marked increase in electrical activity as in severe left ventricular
hypertrophy.
• The left ventricle is electrically dominant in ECG terms as the left ventricular
mass is larger than the mass of the right ventricle. This produces a deep S
wave in V1 as the main direction of the force is away from the lead, and a
tall R wave in V6 as the main electrical force is traveling towards that lead.
Therefore, the QRS complex in the chest leads reflects the left ventricular
activity.
The ECG Paper
The ECG paper consists of vertical and horizontal lines, which divides the paper into
small and big squares. Each small square is 1 millimeter (mm) high and 1 mm (wide),
while each big square is 5 mm high and 5 mm (wide).
Each big square contains 25 small squares and it is outlined in darker ink for easy
counting. In one minute, 300 big squares pass beneath the pointer's needle. The
electrical activity of the heart for one minute will be drawn on the 300 big squares.
• 300 big squares = 60 seconds (1 minute)
• 1 big square = 5 small squares = 0.2 seconds
• 1 small square = 0.04 seconds
The vertical lines measure the amplitude, whereas the horizontal lines measure the
timing of the impulses.
• Each small square equals 0.1 mV
• Each large square equals 0.5 mV
After obtaining the recording on an ECG paper, you can determine the heart rate by
counting the number of squares on the paper, calculate the time taken for each
deflection, and determine the amount of voltage or electrical activity of the heart.
ECG Leads
Electrical pairs called leads are used for recording the electrical activity. Each of
these electrode pairs (leads) will record the electrical activity of the heart as
spotted by them. The standard practice is to use 12 leads to record the heart's
electrical activity. Six of these leads record the electrical activity in the frontal
plane (limb leads), and six of them record the electrical activity in the horizontal
plane (chest leads).
The leads can be bipolar or unipolar.
• Bipolar leads record the electrical activity between the two active electrodes
(positive and negative)
• Unipolar leads record the electrical activity between an active and an inactive
electrode.
The reference electrode for unipolar recordings is formed by connecting the right
arm, left arm, and left leg electrodes together to form a Wilson central terminal
(WCT).
Limb leads
The limb electrodes should be placed on the fleshy, non-bony part of the
patient's upper arms and lower legs. The tabs on the electrodes should be placed
pointing downwards on the arms and upwards on the legs to reduce tension or
pull on the electrodes.
The limb electrodes are of two types:
• Standard limb leads
• Augmented leads
a) STANDARD LIMB LEADS:
• Leads I, II and III are known as standard limb leads.
• They are often considered as the bipolar leads as they record the electrical
activity from two limb electrodes at the same time.
• The standard limb leads have a positive and a negative pole each.
• The limb electrodes are often color-coded and include the abbreviations for the
part of the body where they should be applied as given below.
b) Augmented Leads:
• The limb leads -aVR, aVL and aVF are known as augmented leads. The
abbreviation aV stands for augmented voltage because the electrical impulses
from these three leads are very small and the ECG machine must augment or
increase their size to make them readable.
• The last letter in each of the augmented leads is an abbreviation that relates to the
positive pole or electrode.
• They are unipolar because only a single positive electrode is referenced against a
null point (a point with little or no significant electrical variation) between
remaining electrodes.
C. Chest Leads
• The chest or precordial leads are the last six leads of the standard 12 lead ECG.
They record the electrical activity from a null or midpoint within the heart to
one of the six landmarks on the chest wall where an electrode is placed.
• They do not require any amplification because they are close to the heart.
• These leads are unipolar and are designated as leads V1 through V6.
• The correct placement of the chest electrodes is crucial to obtain an accurate
reading.
The anatomical placement of the chest electrodes is given in the following table.
How to Prepare a Patient for ECG?
You should follow the steps given below while preparing a patient for ECG:
• Charge and keep the ECG machine ready to use.
• Keep adequate ECG paper in the machine for recording.
• Remove patient's clothing to expose the bare chest.
• Remove the electronic device such as mobile phone from the patient as it
can produce an artifact (interference).
• Shave or clip the hair from the electrode sites to ensure proper contact of
the electrodes with the skin.
• Clean the skin thoroughly and lightly rub dry. You can use soap and water,
isopropyl alcohol or special skin pads for cleaning the site of electrode
placement. It makes the skin oil-free and provides better electrode
adhesion.
• Place the patient in supine position.
• Attach the lead wires to the electrodes and apply the electrodes to the
patient in either standard 12-lead configuration or in 3 or 5 lead
configurations.
• Make a small stress loop in each lead wire, and tape the loop to the patient's
skin to minimize the motion artifact.
Normal ECG
The electrical activity of the heart is represented by positive and negative deflection
from baseline. A deflection is an upward or downward movement from the baseline,
which is also known as isoelectric line or the baseline.
Depolarization towards a lead produces positive (upward) deflection whereas,
depolarization away from a lead produces negative (downward) deflection. The
reverse is true for repolarization. In a normal ECG pattern, the waves, intervals, and
segments follow a regular sequence and have normal ranges.
Waves in a Normal ECG
P Wave: It is the first positive deflection (upward movement) that represents the
atrial depolarization (contraction). It is a small round wave and usually has the
duration of 0.08 to 0.10 seconds. It appears upright in the lead I, II, V3, V4, V5, V6,
and aVF. Its polarity is positive in leads I, II, aVF, V4, V5, and V6, and negative in
aVR. It is biphasic in lead V1 and V3.

Q Wave: It is the first negative deflection, and it moves below the isoelectric line.
The normal Q wave is less than 0.04 seconds in duration and is less than 3 mm deep.
Small Q waves are found normally in leads V5, V6 and I. Abnormalities of the Q
waves most commonly indicate myocardial infarction, which will be discussed in
the later part of the module.
R Wave: It is a first upward deflection in QRS complex cause due to ventricular
depolarization. Its duration is less than 0.01 second. The R wave is usually small (<1
mm) in V1 and V2. It increases progressively in height from V3 to V6. The R wave
corresponds to the patient's pulse.

S Wave: It is a negative deflection produced after R wave. It is normally 1/3rd the

height of R wave. In V1 and V2 the R wave is deep as the impulse is going to the
muscles of the left ventricle and then to the right ventricle. It then progressively
diminishes from V1 to V6
T Wave: T wave is an upward deflection, which represents the electrical activity in the
ventricles during repolarization. It appears after the QRS complex. T waves are not as
important in single-lead ECG patterns as they are in 12-lead ECG. In single-lead ECG,
the T-wave shape can be changed by electrode placement and often, normal T wave
appear inverted (negative) or even flattened. However, it appears upright in the lead V2,
V3, V4, V5, and V6.
U Wave: This wave is not seen normally or absent in an ECG. U wave is a small
rounded wave produced by slow and late repolarization of the intraventricular Purkinje
system after the main ventricular mass has been repolarized. Presence of U wave
indicates electrolyte imbalance.
J wave: This wave is not normally seen or absent in an ECG. It is also known as K
wave, H wave, or hypothermic wave. It is a positive deflection which occurs between
the QRS complex and ST segment. It is usually observed in the patients with
hypothermia (body temperature less than 32oC), hypercalcemia or ventricular
fibrillation.
Correlation between ECG and Electrical
Events in the Heart
Intervals and Segments in a Normal ECG
PR Interval: The PR interval is measured from the onset of the P wave to the onset
of the QRS complex. It represents the time taken for the cardiac depolarization to
travel through the atria, AV node, and the bundle of His or Purkinje network. The
normal PR interval is 0.12 to 0.20 seconds. Most of the PR interval constitutes the
time taken for the impulse to reach from AV node to His and Purkinje system as the
AV node has a slow conduction velocity.
PR interval of less than 0.12 seconds is called a shorter PR interval and more than
0.2 seconds is called a long PR interval.
QRS Interval: The QRS complex is measured from the point at which the Q leaves
the isoelectric line to the point at which the S returns to the isoelectric line. It is the
second positive deflection after the P wave. It represents ventricular depolarization
(contraction). The normal QRS complex has a duration of 0.06 to 0.12 second.
In lead, I, aVL, V5 and V6 the duration of QRS complex is less than or equal to
0.04 seconds. It is represented as a positive deflection with a large upright R wave
in the leads I, II, V4, V5, and V6 and as a negative deflection with a large, deep S
wave in aVR, V1, and V2. The R wave gets taller as you proceed from V1 to V6,
whereas the S becomes smaller. In lead V3 and V4, the length of R and S wave
becomes equal and it is known as the transitional zone.

Delay in the conduction through ventricles will produce a wider-than-normal QRS

complex. As the recovery of atria is very less, atrial repolarization is lost behind the
QRS complex.
QT interval:
The QT interval is measured from the onset of the QRS complex to the end of the T
wave. It represents the ventricular refractory time i.e., the time taken for ventricular
depolarization and repolarization. The QT interval represents the ventricular
refractory time. Factors that affect the QT time interval are age, gender, and heart
rate. As the normal QT interval time range varies with heart rate, it is important to
compare the QT interval obtained with a table.
While measuring QT interval, you have to correct (normalize) it for the heart rate
using the Bazett's formula. According to this formula, the corrected QT interval
(QTc) can be derived by dividing the QT interval by the square root of the RR
interval (in seconds).
RR Interval: The RR interval in an ECG is calculated from the peak of the one R
wave to the end of the succeeding R wave peak. It represents the time between
two successive ventricular depolarization. The duration of RR interval depends on
the heart rate. When the heart rate is fast, the RR interval is shorter and when the
heart rate is slow, the RR interval is longer.

ST Segment: The ST segment in the ECG represents the part from the end of the
QRS complex to the beginning of the T wave. It is horizontal in the initial part and
gradually ascends towards, and merges with the ascending limb of the T wave. It
represents the time during from ventricular depolarization to ventricular
repolarization. It is along the isoelectric line.
TP segment:
TP segment in the ECG represents that the atria and ventricles are relaxed and the
heart is in a diastolic state. TP segment is on the isoelectric line. It begins at the
end of the T wave and ends at the beginning of the P wave. The duration of the
TP segment is 0.0 to 0.40 second or greater. It depends on the heart rate and the
configuration of the P waves and the QRS complex. When the heart rate is fast,
the TP segment is shorter than when the heart rate is slow. When the heart rate is
≥ 120 bpm, the TP segment is absent, as the P wave immediately follows the T
wave. On the other hand, when the heart rate is ≤ 30 bpm, the TP segment is
about 0.4 seconds or greater.
ECG Patterns and the Refractory Periods
The heart has different phases of refractory periods as it proceeds to various phases
of polarization, depolarization, and repolarization. The term refractory means
resistance to depolarization of the cells. The three refractory periods
of the heart are:
• Absolute refractory period
• Relative refractory period
• Diminished refractory period
These refractory periods can be compared to the various phases of the ECG pattern.
Absolute refractory period:
It refers to the phase of the cardiac cycle during which no further depolarization can
take place no matter how strong the stimulus is. It starts at the beginning of the
depolarization phase and extends into the very early part of the repolarization phase.
On a normal ECG pattern, the absolute refractory period (ARP) extends from the
beginning of the QRS complex (ventricular depolarization) across the ST segment
(early phase of ventricular repolarization) to the beginning of the T wave (still early
ventricular repolarization).
Relative refractory period:
It refers to the phase of the cardiac cycle during which depolarization can occur if
there is a strong enough stimulus. On a normal ECG pattern, the relative refractory
period (RPP) begins near the starting point of the T wave (early ventricular
repolarization) and includes most of the T wave (middle and late ventricular
repolarization). The RRP ends at the point where the diminished refractory period
begins.
The RRP is a dangerous part of the cardiac cycle as a strong external stimulus such
as electrical shock or internal stimuli such as impulse discharged from the AV node
can cause abnormal myocardial activity.
Diminished refractory period:
It refers to the phase of the cardiac cycle during which the myocardial cells are still
resistant to stimuli but depolarization can occur even with a relatively weak stimulus.
On a normal ECG pattern, diminished refractory period (DRP) extends from the end
of the T wave (the end of the ventricular repolarization) across the baseline
(repolarization), through the P wave (atrial depolarization) and PR segment (delay of
the impulse in the AV node).
Each complete cardiac cycle takes about 0.8 seconds, with each wave taking an
appropriate amount of time as mentioned above. By observing and measuring the
size, shape, and location of each wave on an ECG recording, you can analyze and
interpret the conduction of electricity through the cardiac cells, rhythm, and rate of
the heart, and the functioning of the heart in general.

Interpreting and Analyzing ECG

ECG helps to evaluate the rate, regularity, and functioning of the heart. There are
eight steps to interpret and analyze an ECG, which you should follow to determine
the functioning of the heart.
Step 1 Determine the heart rate:
The first step to determine the functioning of the heart through an ECG is to calculate
the heart rate. The ECG records the atrial and ventricular activity during each cardiac
cycle. Therefore, determining the rate of ventricular activity on the ECG, you can
interpret the heart rate of your patient.
The heart rate can be determined by using the following methods:
• 6-second count method
• Heart rate calculator ruler
• RR interval method
• The rule of 300
Step 2 - Determine Regularity:
After determining the heart rate, you should determine the regularity by following
the steps given below:
• Estimate the RR interval by counting the small squares between R waves or by
using ECG calipers
• Compare the RR interval to each other.
Lead II, which usually gives a good view of the P wave, is most commonly used to
record the rhythm strip.
If the shortest and longest RR interval varies by less than 0.08 seconds (two small
squares) in an ECG strip, then the rhythm it is considered as regular rhythm.
If the shortest and longest RR interval varies by more than 0.08 seconds, the
rhythm it is considered an irregular rhythm.
Irregular rhythm is classified as:
• Regularly irregular: In this case, the irregularity has a pattern and it is also
called as group beating
• Occasionally irregular: In this case, only one or two RR intervals are unequal.
• Irregularly irregular: In this case, the rhythm is totally irregular and no
relationship is seen between the RR intervals
Step 3 - Identify and analyze the waves:
• After determining the rhythm, you should identify and analyze the P and T
wave. The normal P wave in lead II is positive, smoothly rounded and usually
precedes each QRS complex. You should check if all the P waves appear to be
the same size and shape and are followed by QRS complex.
• The rate of P wave and QRS complex rate should be the same if the patient has
normal conduction. Howe ever, in case of complete heart block the rate can be
same but the P waves are not associated with QRS complexes. A QRS
complex is absent in the patients with atrioventricular (AV) block. An
abnormal P wave may be positive, negative, or flat. Its height may be less than
0.5 mm or greater than 2.5 mm. Its duration may be greater than 0.10 sec.
• T waves are rounded in shape and follow the QRS complex. You should check
if all the T waves appear to be the same size and shape and follow QRS
complex.
Step 4 - Analyze the QRS complex:
After analyzing the P and T wave, check the QRS complex. Normally, the QRS
complexes gave a duration of ≤ 0.12 sec or a width of less than three small squares.
You should check the appearance, regularity, and duration of QRS complex across
the ECG strip. If the QRS complex is greater than 0.12 second or less than 0.10
second, it indicates abnormal conduction in the ventricles.
Step 5 - Determine the PR interval:
The PR interval indicates the time taken by an impulse to reach the AV node from
the atria. The normal length of the PR interval is 0.12 to 0.20 second. A short PR
interval (less than 0.12 seconds) indicates that the impulse progressed
from the atria to the ventricles through the pathway but not via the AV node. This is
known as an accessory pathway syndrome or Wolff-Parkinson-White syndrome. A
longer PR interval (more than 0.20 seconds) indicates a first degree AV block.
Step 6 - Determine the axis
You can use any of the two methods to determine the patient's electrical axis.
The Quadrant method: It is the fast and easy way to plot the heart's axis. It
involves observing the main deflection of the QRS complex in leads I and aVF.
Lead I indicate whether impulses are moving to the right or left and lead
aVF indicates whether the impulses are moving upward or downward. If the
QRS complex deflection is positive or upright in both leads, the electrical axis is
normal. If the QRS complex is negative in lead I, and positive in lead aVF, it
indicates that impulse is moving away from lead I, and towards lead aVF. In
such condition, the axis lies in the lower right quadrant and indicates a right axis
deviation. Negative depolarization in both the leads indicates extreme axis
deviation.
Isoelectric lead method: It is the more precise axis calculation method as it gives an
exact degree measurement of the electrical axis. It allows you to determine the axis
even if the QRS complex is not clearly positive or negative in leads I and aVF. You
should follow these steps to use this method:
• Review all six leads, and identify the lead that contains either the smallest QRS
complex or the QRS complex with equal deflections above and below the baseline
(i.e. Q and R waves are of the same height).
• Use the hexaxial diagram to identify the lead perpendicular to the lead which has
the smallest QRS complex or the QRS complex with an equal deflection above
and below the baseline. For instance: If lead, I have the smallest QRS complex
then the lead perpendicular to the line representing the lead I would be lead aVF.
• After identifying the perpendicular lead, examine its QRS complex to check if the
deflection is positive or negative. If the QRS complex in the perpendicular lead
(aVF in this example) is positive, it indicates normal axis.
The determination of the cardiac axis helps to diagnose conduction defects, ventricular
enlargement, broad complex tachycardia, atrial septal defects, Wolff-Parkinson-White
syndrome, and pulmonary embolus.
Step 7 - Evaluate for hypertrophy
Hypertrophy in a heart chamber indicates an increased thickness of the chamber wall. It
is caused by an increase in afterload. In left ventricular hypertrophy, the left ventricular
wall becomes very thick and results in a large S wave in V1 and a large R wave in V5.
Step 8 - Evaluate for ischemia/infarct
Ischemia is associated with reduced blood supply and myocardial infarction is associated
with complete occlusion of the coronary artery. The ECG can show which coronary
artery is occluded and reveal any blocks in the ventricular conduction caused by the
infarction.
Normally the T wave is upright when the QRS is upright. An inverted T wave
indicates ischemia. An additional indicator of ischemia is ST segment depression
caused due to increased demand for blood flow to the arteries than the normal
capacity of the heart. An elevation of the ST segments denotes recent injury and
is the earliest consistent sign of infarction.
You will learn more about the ECG pattern associated with various cardiac
disorders in the next lessons of the course.