SPDX 311 DASH

NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

ELECTROCARDIOGRAPHY

OUTLINE PURPOSE OF ECG

01 History detects the heart’s electrical rhythm and produces
02 Electrocardiography 
what’s known as a tracing
03 Important Diagnostic Tool in the Evaluation of CVD tracing consists of representations of several waves

04 Purpose of ECG that recur with each heartbeat
05 Cardiac Cycle wave pattern should have a consistent shape, if the
06 Normal Electrical Conduction Pathway  waves are not consistent or if they don’t appear as
07 ECG Setup standard waves, this is indicative of heart disease
08 Types of ECG
09 ECG Leads CARDIAC CYCLE
10 ECG Waves  sequence of events, electrical and mechanical events,
11 ECG Rules taking place in the heart from the beginning of one
12 Examination Protocol heart beat initiated by an impulse from the SA node to
13 Interpreting the Results the beginning of the next heat beat also initiated by
an impulse from the SA node
HISTORY
Electrical depolarization and repolarization of the
Dr. Luigi Galvin first noted that electrical current events atria ventricle
1786
could be recorded from skeletal muscles Mechanical contraction or relaxation of the atria and
first “ electrogram” (ECG) from the intact human events ventricles
heart was recorded with a mercury capillary
1887
electrometer by Augustus D. Waller at St. Mary’s NORMAL ELECTRICAL CONDUCTION PATHWAY
Hospital London
Einthoven, using an improved electrometer and a
correction formula developed independently. He
1895
labeled the corrected derived deflections PQRS
and T
first article source using the term
1900
“ Elektrokardiogram” (EKG) by Willem Einthoven
Einthoven publishes the first electrocardiogram
1902
recorded on a string galvanometer
Apple smart watch: over 400,000 people enroll in
a study being conducted by researchers at
2018 Stanford and Apple to determine whether a
wearable technology can identify irregular heart
rhythms suggestive of atrial fibrillation

ELECTROCARDIOGRAPHY (ECG/EKG)
 measures the heart’s electrical activity

IMPORTANT DIAGNOSTIC TOOL IN THE EVALUATION OF

CARDIOVASCULAR DISEASE (CVD)
 Abnormal heart rhythm (arrhythmias)
 Myocardial ischemia / infarction
 Chamber enlargement
 Electrolyte abnormalities
SPDX 311 DASH
NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

ECG SETUP

Exercise/Stress
ECG Tracing

Holter Monitor

ECG LEADS
BIPOLAR LIMB LEADS
Lead 1 right arm and left arm (+)
Lead 2 right arm and left leg (+)
Lead 3 left arm and left leg (+)

TYPES OF ECG

Resting ECG
Tracing

UNIPOLAR LIMB LEADS

 ECG machine usually augments the potential by 1.5
than the original potential
 comes from a central terminal
SPDX 311 DASH
NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

Lead aVR towards right arm ECG WAVES

Lead aVL towards left arm
Lead aVF towards left foot

P wave  represents atrial depolarization

 represents ventricular depolarization
 corresponds to phase 0
intraventricular septum
Q wave
QRS wave depolarization
R wave apical depolarization
depolarization of the base of
S wave
the ventricle
 represents ventricular repolarization
T wave
CHEST LEADS  corresponds to phase 3 of repolarization
 uncommon wave that is believed to be
 landmark: Angle of Louis U wave due to the slow repolarization of
 represent the horizontal plane of the heart papillary muscles
 starts at the end of S to the beginning of
POSITION OF CHEST LEADS ST T
V1 4th intercostal space, left parasternal border segment  represents phase 2 of ventricular
4th intercostal space, right parasternal repolarization
V2
border  starts at the end of S to the end of T
V3 located between V2 and V4 ST interval  measures the whole period of latent
5th intercostal space, left midclavicular line repolarization
V4
(usually located below the nipple)
left anterior axillary line, at the same level as TWO FORMS OF WAVES IN THE ECG
V5
V4
same level as V4 and V5 but located at the P, R, and T waves are the common
V6 Positive wave
mid axillary line positive waves
Lead V4R same level as V4 but located on the right Negative wave normal negative are the Q and S wave
Lead V3R between V1 and V4R
ISOELECTRIC LINE
 basis for the positive and negative waves
SPDX 311 DASH
NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

ECG RULES POST EXAMINATION

upward  you should be able to go back to your normal diet and
depolarization towards (+) electrode activities, unless your doctor tells you differently
downward  generally, there is no special care after an
depolarization away from (+) electrode electrocardiogram (ECG)
downward  tell your doctor if you develop any signs or symptoms
repolarization towards (+) electrode you had before the ECG (example: chest pain,
upward shortness of breath, dizziness, or fainting)
repolarization away from (+) electrode
NOTE: When reading the ECG, look at the:
Atrial o name
first to depolarize and first to repolarize o age
muscle
Ventricular o date
first to depolarize and last to depolarize o standardization
muscle

EXAMINATION PROTOCOL INTERPRETING THE RESULT

PRE-EXAMINATION TRACING

 remove any jewelry or other objects that may  consists of repeated waves that have a standard
interfere with the test shape
 depending on the reason for ECG, doctor may ask you  waves have section names the P wave, QRS complex,
to stop taking some of your medications ST segment, and T wave
 there is also a PR interval between the P wave and the
EXAMINATION QRS complex, and a QT interval between the QRS
complex and the T wave
 remove clothing from the waist up
 lie flat on a table or bed for the test
 if your chest, arms, or legs are very hairy, the
technician may shave or clip small patches of hair, as
needed, so that the electrode will stick closely to the
skin
 electrode will be attached to your chest, arms, and legs
 lead wires will be attached to the electrodes STANDARD
 once the leads are attached, the technician may enter
identifying information about you into the machine’s
computer
 ECG will be started, it will take only a short time for the
tracing to be completed
 once the tracing is completed, the technician will
disconnect the leads and remove the skin electrode

Standard voltage each 1 mv gives 10 mm (1cm)

sensitivity calibrator deflection
Standard paper speed 25 mm/sec
Each small square 1mm x 1mm = 0.04 sec
Each large square 5mm x 5mm = 0.2 sec
300 large square = 1500 small
Each minute (60 secs)
square
SPDX 311 DASH
NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

TERMINOLOGIES DETERMINING THE AXIS

 look at leads I and aVF
Waveform movement away from the
 use your hands as guide
baseline in either a positive
Lead I left thumb
or negative direction
Lead aVF right thumb
Right Thumb Up right axis deviation
Segment line between wave forms Left Thumb Up left axis deviation
Two Thumbs Up normal
extreme right axis deviation /
Two Thumbs Down
indeterminate axis

Interval waveform and segment

Complex consists of several

waveforms

FRONTAL PLANE LEADS (LIMB OR EXTREMITY)

ABNORMALITIES DETECTED ON ECG

 not all abnormalities can be detected, the only
abnormalities that can be detected are:
arrhythmia
o bradycardia, tachycardia

o abnormal pacemakers
o heart block
 myocardial ischemia / injury / infarction
 cardiac enlargement
 hyperkalemia / hypokalemia
 hypocalcemia

Positive travel towards the lead (upward)

Negative travels away from the lead (downward)

RULE OF THUMB
Positive Negative

P wave atrial depolarization

QRS complex ventricular depolarization
T wave ventricular repolarization
SPDX 311 DASH
NINE
Prelim - Lecture / Roxanne Eushika Medina Week 04

CLINICAL CONDITIONS IONIC IMBALANCE

ISCHEMIA very tall T (peaked T
waves that is the same
 look for ST depression Hyperkalemia
as QRS)

prominent U wave (3-

5mm of U wave)
Hypokalemia

prolonged ST and QT
VENTRICULAR HYPERTROPHY / CARDIAC ENLARGEMENT
Hypocalcemia intervals
 very tall R waves
 very deep S waves
 QRS interval is >0.10 sec

Right Ventricular
tall R waves in V1, deep S waves in V6
Hypertrophy
Left Ventricular
tall R waves in V6, deep S waves in V1
Hypertrophy

R wave S wave
RVH very tall in V1, V2 very deep in V5, V6
LVH very tall in V5, V6 very deep in V1, V2