Basic ECG for beginners

DEMYSTIFYING THE ECG

: Section A

ANATOMY AND PHYSIOLOGY OF THE HEART

AND THE CONDUCTION SYSTEM
The anatomy of the heart

BACK TO THE BASICS

Basic anatomy :

• The heart has four surfaces:

• anterior surface
• Inferior surface (diaphragmatic)
• Posterior surface
• Lateral (free lateral-left) surface
Basic anatomy (cont.)

• The heart also has 4 borders:

• The upper border
• The left border
• The right border

• The inferior border

• The borders are less well defined and are defined

arbitrarily
Basic anatomy (cont.)

There is also base and an apex

The heart lies on the diaphragm occupying the
anterior and the middle mediastinum between the
left and the right lungs
The heart is generally directed downwards,
outwards and to the left
Most of the heart lies behind and to the left of the
sternum
Right to the sternum there is only the right atrium
with the superior and inferior venae cava
The anterior surface :

Right atrium
Right ventricle
partly by left ventricle and the left atrium mainly
the auricle.
It is bound by the right border, upper border, left
border and inferior border
The inferior (diaphragmatic ) surface :

2/3 of the surface is composed of the left ventricle

1/3 of the surface is composed of the right ventricle
Its bound by the right border and left border
The lateral (free lateral-left)surface:

Composed of the left ventricle and the left auricle

and the outflow tract of the left ventricle
The apex is made up of the left ventricle
It is bound by the left border and upper border
The posterior surface :

Small surface
Made up of the left atrium mainly with the four
pulmonary veins with a small part of the right
atrium with the superior and inferior venae cava
Its located near the base of the heart
The left ventricle :

• The left ventricle has a conical shape and has :

• Four walls :
• Septal wall
• Anterior wall
• Lateral wall
• Inferior wall
• The apex
: The coronaries

The heart is supplied by the coronary arteries

The coronary arteries originates from the aorta
There is the right coronary artery
And there is the left main coronary artery which is short and
divides into the left anterior descending and the left circumflex
arteries
The coronary arteries are end arteries with no or minimal
collaterals so any sudden obstruction will cause acute
myocardial infarction
With chronic ischemia the coronaries can develop collaterals
There is variability in the anatomic distribution of the coronary
arteries in some people
The anatomy of the conduction
system
The basic anatomy :

 The conducting system of the heart consists of cardiac

muscle cells and conducting fibers (not nervous tissue) that
are specialized for initiating impulses and conducting them
rapidly through the heart
 They initiate the normal cardiac cycle and coordinate the
contractions of cardiac chambers. Both atria contract
together, as do the ventricles, but atrial contraction occurs
first.
 The conducting system provides the heart its automatic
rhythmic beat
The basic anatomy (cont.) :

This pathway is made up of several elements:

• The Sino-atrial (SA) node
• The inter nodal tracts

• Bachmann bundle

• The atrio-ventricular (AV) node

• The bundle of His

• The left and right bundle branches

• The Purkinje fibers

• The left bundle has an anterior fascicle and a posterior fascicle

The nodes are supplied by the LCX and the RCA
The conduction system is supplied by the RCA and the LAD
The basic anatomy (cont.) :

The SA node :
• located in the right atrium near the superior vena cava and in the epicardium
(near the surface of the heart)
• It is supplied by the sympathetic system through B1 and B2 receptors but
mainly B1
• It is also supplied by the vagus nerves through the muscarinic receptors
• The inter nodal tracts :
• There is three inter nodal pathways which conducts the electric
impulse to the atrium from the SA node and terminating at the AV
node
• The Bachmann bundle a large bundle that traverse through the right
and left atrium mostly carrying impulse from SA node to both atria at
same time
• They are as well supplied by sympathetic and parasympathetic fibers
: The basic anatomy (cont.)

Atrioventricular node :
• The node is located in the right atrium near the tricuspid valve
• It has three parts anatomically
• It is supplied by the sympathetic fibers and parasympathetic
fibers
Bundle of hiss :
• The bundle of hiss is a short structure which connects the AV
node with the right and the left bundle branches and it conveys
the impulse from the AV node to the ventricles from the atrium
• It perforates the fibrous ring (the cardiac skeleton) which
isolates the atria and the ventricles , so it is the only normal
connection between them
The basic anatomy (cont.) :

• The bundles :
• The bundle branches originate at the superior margin of the
muscular inter ventricular septum, immediately below the
membranous septum
• The left bundle branches off and the right bundle continues
downward , coursing on the right side of the septum down to the
apex of the right ventricle and to the papillary muscles
• The left bundle branches into anterior and posterior fascicle
although this is not true for some people
• The terminal Purkinje fibers :
• connect with the ends of the bundle branches to form interweaving
networks on the endocardial surface of both ventricles, which
transmit the cardiac impulse almost simultaneously to the entire
right and left ventricular endocardium. They penetrate only the inner
third of the endocardium
The depolarization and the
repolarization
: Basic physiology

Each part of the conduction system has its own

pattern of depolarization and each part has its own
rhythmogenecity (the ability to induce rhythm and
pace the heart)
Conduction across the conductive system differs
according to the segment conducting the impulse
and some parts causes delay of impulse
The cardiac muscle itself can conduct electrical
impulse but in pathological conditions
it even may initiate its own rhythm
Basic physiology (cont.) :

The nodes and the atrial conductive systems are supplied by 2 vagus
nerves and 2 sympathetic chains
The conduction system of the left ventricle (the left and the right bundles ,
and the purkinje fibers ) are supplied by the sympathetic nerves only
Bundle of hiss has no autonomic supply
The effect of the vagus and sympathetic systems differs from each other on
the SA and AV node (SA node affected first , and effects of the vagus starts
more rapid and terminates rapidly while sympathetic starts rapidly and
ends more slowly)
The Sino atrial node (SA node) is the normal and physiological pacemaker
of the heart as it is the fastest self-depolarizing tissue in the heart and it
discharges in a regular fashion with a fixed rate
In case of failure of the SA node other tissues in the conduction system
takes place and paces the heart according to its own arrhythmogenicity
: Basic physiology (cont.)
Section B:

THE BASICS OF THE ECG : THE MACHINE,

”T H E L E A D S A N D T H E “ P A P E R
The machine
What is an ECG :

The ECG machine was invented since 1895 by Einthoven

The ECG stands for electrocardiograph which is a machine which
reads the electric activity of the heart
Through out the cardiac cycle the electric activity of the heart
changes so each part of the cycle can be represented by the ECG
electrically
The ECG machine can print the cardiac electrical activity on a
paper or present it on the monitor
The electric activity is recorded through the ECG leads
It is a non-invasive modality
There is no contra indications for the ECG and the ECG is not
harmful to the patient nor for the health care providers
What is an ECG (cont.) :

 The ECG can be recorded at rest or under stress (with

exercise or drugs)
 ECG can be a fixed machine in the health care facility or a
portable machine which can be attached to the patient for
several days (such as holter monitor or loop recorders)
 It can be a monitor in the ICU or in the operating room
continuously monitoring the patient in real time
: Indications and drawbacks of the ECG

 There are many indications for ECG including :

• Identifying the cardiac rhythm and its type
• Diagnosing myocardial infarction and ischemia
• bundle branch blocks

• Monitoring for drug toxicity and electrolyte imbalance

• Diagnosing pericarditis

• Diagnosing myocarditis

• The disadvantages of ECG include :

• It needs a lot of training to interpret correctly

• Can be affected by electrical artifacts or muscle twitches

• Can be non specific in some cases

• It can give false “reading” : pulseless electric activity

The leads

THE OCTOPUS ARMS

Introduction :

ECG leads are the wires attached to the patient to record the electric
cardiac activity to be printed and analyzed by the machine
The leads can also refer to the different “angles” from which the ECG
machine sees and records the electric activity of the heart
The ECG has 12 standard leads “angles” :
• 6 limb leads which are called I, II ,III ,aVL ,aVR, and aVF
• 6 chest leads V1 , V2 , V3 , V4 , V5 , V6
• There is also the 3 leads system and the 5 leads system which are used in
ICU and intra operative monitors ,holter monitors and loop recorders
• The 3 lead system will record the limb leads I , II , III only and the five lead
system can record all the 6 limb leads and V1
• The 3 leads system has three wires attached to the patient
• The 5 leads system has 5 wires attached to the patient
• the 12 lead system has 10 wires attached to the patient
Introduction (cont.) :

The limb leads record the electrical activity of the heart on the vertical plane
( as if the patient is sliced coronaly and viewed electrically)
The chest leads record the electric activity on the horizontal plane (as if the
patient is sliced axially and viewed electrically)
The electric activity in the heart starts at the SA node normally and spreads
towards the base of the heart and then reflected back to the base so it will be
moving toward a certain lead “angle” and away from another lead at the same
time giving opposite views
Each lead has a positive terminal and a negative terminal
If there is no electrical activity the lead will not record anything and will give
an isoelectric line (the baseline)
If the electrical impulse is moving towards the positive terminal it will be
interpreted as a positive wave in the ECG (above the baseline) and if it moves
away from the positive terminal and towards the negative terminal it will be
interpreted as a negative wave in the ECG (below the baseline)
If the wave is perpendicular to the lead the negative and positive waves will be
equal to each other (biphasic wave)
: The limb leads

The limb leads is the term applied to the 6 “angles” which view the heart
from the vertical (frontal) plane
The limb leads “electrodes” are attached to the patient limbs (right and left
arms and legs)
Originally there was 3 leads : I,II,III
Augmented leads were invented later on to enhance the recording ability of
the ECG : aVL , aVR , aVF (Goldberger leads)
Leads I,II,III are bipolar leads which has a positive and a negative terminals
Leads aVL,aVR,aVF are called unipolar leads which compares its results to
an imaginary reference point(modified central Wilson`s terminal) in the
centre of the heart-in other words each limb is the positive terminal and all
other limb leads are combined together to form the negative terminal
All limb leads are related to each other through the Einthoven triangle and
the Einthoven law
The limb leads (cont.) :

Leads II ,III and aVF are called inferior leads as they “look” at
the inferior surface of the heart
I , aVL are called high lateral leads as the “look” at the high
lateral surface of the heart
All of the limb leads have their positive terminal towards the
left side in accordance to the main electrical axis of the heart
aVR is opposite to all limb leads as it has it`s positive terminal
placed on the right arm opposite to the main electrical axis of
the heart
All leads records the electrical activity of the heart at the same
time but the inferior leads best records the inferior surface and
the lateral leads best records the lateral surface of the heart
The Einthoven triangle and law :

There are four electrodes:

• The right electrode (attached to the right arm or shoulder) (RA)
• The left electrode (attached to left arm or shoulder) (LA)
• The lower electrode (attached to left leg) (LL)
• The ground electrode (attached to right leg)
• Each one of the electrodes (except the ground) can be a positive or a negative
terminal
• In lead I the left electrode is the positive terminal and the right electrode is the
negative terminal
• In lead II the right electrode is negative and the lower limb electrode is positive
• In lead III the left electrode is negative and the lower electrode is positive
• This forms the basis of the imaginary Einthoven triangle which imagines the
body as having three electrical terminals in a form of inverted triangle and each
electrode is place on each terminal and the heart is the centre of this electrical
triangle
• Einthoven law states that : I+(-II)+III=o
The limb leads vectors :

“Vectors” refer to the direction of the lead “angle”

It can also refer to the average sum of the total cardiac electric activity
According to the Einthoven triangle lead I is directed from the right
shoulder to the left shoulder horizontally in a straight line so zero
degree will be at the left arm(positive electrode) and ± 180 degree will
be at the right arm(negative electrode)
Lead II is directed from the right arm to the left leg so its vector is
directed obliquely towards the left leg and +60 degree will be at the left
leg (positive electrode) and -120 degree will be at the right arm
(negative electrode)
Lead III is directed from the left shoulder to the left lower limb so its
vector is directed towards the left leg and +120 degree will be at the left
leg (positive electrode) and -60 degree will be at the left shoulder
(negative electrode)
The limb leads vectors (cont.):

Lead aVF is directed from an imaginary point at the centre of the heart
towards the left lower limb so its vector is directed vertically towards the
left lower point and +90 degree will be at the left lower limb (positive
electrode) and -90 degree will be at the imaginary point(negative electrode)
Lead aVR is directed from an imaginary point at the centre of the heart
towards the right arm so its vector is directed obliquely towards the right
arm and -150 degree will be at the right arm (positive electrode) and +30
degree will be at the imaginary point(negative electrode)
Lead aVL is directed from an imaginary point at the centre of the heart
towards the left arm so its vector is directed towards the left arm and -30
degree will be at the left arm and +150 degree will be at the imaginary point

All these vectors are combined together forming the hexaxial reference
system its also called the Cabrera system
-Optional-

Wilson`s terminal is the average between all limb

electrode : Vw = 1/3(RA+LA+LL)
aVR = RA – ½(LL+LA) = 3/2 (RA-VW)
aVL = LA – ½(RA+LL) =3/2(LA-Vw )
aVF =LL – ½(RA+LA) = 3/2(LL-Vw)
Modified Wilson's terminal averages all out to zero
Lead II is inverted with respect to the originally
planned lead as it caused the QRS to be mostly
negative and Einthoven didn’t like it so he inverted
it to keep the QRS positive!
: The chest leads

The chest leads were later on inverted after the limb leads and the
augmented leads
Chest leads (pericordial leads) is the term applied to the 6 “angles”
which views the heart from the vertical plane
Chest leads are called the V leads (for ventral)
There are the standard chest leads V1-V6
The chest leads “electrodes” are attached on the chest wall of the
patient
The chest leads are unipolar leads and each electrode compares its
results to an imaginary reference point (modified Wilson's central
terminal) in the centre of the chest-in other words each lead is the
positive terminal and all the other limb leads are considered to be
the negative terminal
The chest leads (cont.) :

 Chest leads “looks” at the heart “circumferentially” :

• V1-V2 are septal leads as they “look” at the septum
• V3-V4 are anterior leads as they “look” at the anterior wall of the
hear
• V5-V6 are lateral leads as they “look” at the free lateral wall of the
heart
• Some authors combine V1-V4 as anterior leads with no distinction
between leads
• All leads records electrical activity of the heart at the same time but
the best area recorded is the area just below the lead “electrode”
• The right ventricle and the posterior surface of the heart are not
recorded in the standard 12 lead ECG
: Non-standard leads

 There are extra leads which are not part of the standard 12
lead ECG but are useful in some clinical situations , they
include :
• Posterior chest leads : which “looks” at the posterior wall of the
heart and are named V7-V9
• Right chest leads which “looks” at the right side of the heart
and the right ventricle specifically and are named V1R-V6R
’The ‘paper
The shape and the structure of the ECG paper :

The ECG paper is divided into small and large boxes

The horizontal side (the width) of the box represents the time
interval in seconds or milliseconds
The vertical side (the height) of the box represents the
amplitude interval in mV
Each large box consists of 5 small boxes in width and height
Each small box represents 0.04 sec or 40 mSec in width and 0.1
mV in amplitude
Thus the large box represents 0.2 sec or 200 mSec in width and
0.5mV in amplitude
The small box measures 1mmX1mm and the large box measures
5mmX5mm
The standards :

In order to give the ECG the standard shape the ECG
machine must print on the paper with a certain speed
and certain amplitude to give the standard intervals on
the ECG paper
Standardization is important to allow ECG comparison
and detect progressive lesions
The ECG machine should be calibrated to compare its
readings to 1 mV
The paper speed should be 25 mm/sec
On the basis of these settings the intervals will be
adjusted according to the standard
Out of standards :

ECG can be printed by the machine in other different

speeds and amplitudes but the small and large boxes
will give different readings according to the
calibration:
• Changes in the voltage calibration can be :
• Half voltage :
• In this case the ECG will compare its readings to 0.5 mV
• the height of each small box will represent 0.05 mV and each large
box 0.25 mV
• It should be used in patients with QRS complexes of very high
amplitude interfering with the ECG interpretation or exceeding the
size of the paper when waves are too large to be seen
example
:Out of standards (cont.)

• Double voltage :
• In this case the ECG will compare its readings to 2mmV
• In this case the height of each small box will represent
0.2 mV and the height of the large box will represent
1mV
• Should be used when the ECG has low amplitude
interfering with the ECG interpretation waves too small
to be seen correctly
Example
Out of standards (cont.):

ECG can be printed in different speeds :

• Double speed :
• The ECG paper will be printed at a speed of 50mm/sec
• In this case each small box will represent 0.08 sec or 80
mSec in length and each large box will represent 0.4 sec
or 400 mSec
• Used in the tachy arrhythmias when the rhythm is too
fast to be interpreted so the waves can be seen more
easily
example
:Out of standards (cont.)

• Half speed :
• The ECG will be printed at a speed of 12.5mm/sec
• In this case each small box will represent 0.02 sec or
20 mSec in length and each large box will represent 0.1
sec will 100mSec
• Rarely used clinically but can be used if the rhythm is
too slow to be interpreted and to detect certain patterns
in tachy or brady arrhythmias
Example
Out of standards (cont.):

The ECG can be printed in double speed and double

rhythm specially in the tachyarrhythmias as if the
ECG is ‘zoomed’
When reading an ECG ,the speed and the voltage
calibration of the ECG should always be checked
When following up a patient all the ECGs should
have the same configuration so the serial ECGs can
be compared
Section C :

THE ECG WAVES AND ITS RELATION TO THE

CARDIAC CYCLE
Introduction :
The P wave :

 The P wave is the first positive deflection on the ECG

 It represents atrial depolarization in the normal conditions
after being depolarized by the sinus node
 The sinus node itself has no representation in the ECG
 It is most easily seen in the inferior leads (II, III and aVF)
and lead V1, as the P waves are most prominent in these
leads as the vector of atrial depolarization is directed
generally towards the positive electrode of these leads
The P wave (cont.) :

Characteristics of the Normal Sinus P Wave:

• Morphology
• Smooth contour
• Monophasic in lead II (above the baseline)
• Biphasic in V1 (half of it is above the baseline and the other half is below the
baseline)
• Axis (direction):
• Normal P wave axis is between 0° and +75°
• P waves should be upright in leads I and II, inverted in aVR
• Duration :
• < 120 ms (3 small squares)
• Amplitude :
• < 2.5 mm in the limb leads ( 2 and half small squares)
• < 1.5 mm in the pericordial leads (1 and half small squares)
Relation of the P wave to the atrial depolarization:

Atrial depolarization proceeds sequentially from right to left, with

the right atrium activated before the left atrium.
The right and left atrial waveforms summate to form the P wave.
The first 1/3 of the P wave corresponds to right atrial activation, the
final 1/3 corresponds to left atrial activation; the middle 1/3 is a
combination of the two.
In most leads (e.g. lead II), the right and left atrial waveforms move
in the same direction, forming a Monophasic P wave.
However, in lead V1 the right and left atrial waveforms move in
opposite directions. This produces a biphasic P wave with the initial
positive deflection corresponding to right atrial activation and the
subsequent negative deflection denoting left atrial activation.
: Section D

THE ABNORMAL WAVES

Abnormalities of the P wave
Introduction :

 P wave can be abnormal in :

• Amplitude
• Width
• Morphology
• Axis

• Every change is indicating to a certain abnormality mainly

in the atria
• P waves can indicate sinus rhythm-normally- or may
indicate atrial rhythm
• They may be related or not related to the QRS complex
Change in amplitude-the right atrial enlargement:
 In right atrial enlargement, right atrial depolarization lasts longer
than normal and its waveform extends to the end of left atrial
depolarization
 Although the amplitude of the right atrial depolarization current
remains unchanged, its peak now falls on top of that of the left
atrial depolarization wave
 The combination of these two waveforms produces a P waves that
is taller than normal (> 2.5 mm), although the width remains
unchanged (< 120 ms)
 There is another sign inV1 suggesting right atrial abnormality, the
initial positive portion of the biphasic P wave is larger than the
terminal negative portion.
 Right atrial enlargement is also called P-pulmonale or peaked P
Change in width – the left atrial enlargement :

 In left atrial enlargement, left atrial depolarization lasts

longer than normal but its amplitude remains unchanged.
 Therefore, the height of the resultant P wave remains
within normal limits but its duration is longer than 120 ms
(3 small squares)
 A notch near its peak may or may not be present
 A biphasic P wave in V1, with its terminal negative
deflection more than 40 mSec wide(1 small square) and
more than 1 mm(1 small square) deep -1x1-is another ECG
sign of left atrial abnormality.
 Left atrial enlargement is also called P-mitrale or bifid P
Change in morphology and axis :
 P waves are supposed to be smooth and should be upright in leads I
and II and inverted in aVR
 If the axis is different this may indicate that the atria were not
depolarized in the usual pattern and sequence and the atria are being
depolarized differently by a different pacemaker with different pattern
and sequence
 The P wave can indicate the origin of that abnormal pacemaker that can
be either from the atria or from the AV node (junctional)
 In other words not all P waves are indicators of normal sinus rhythm
 P wave can be deformed as a result of biatrial enlargement
 It can be totally absent and replaced by small irregular waves as in
atrial fibrillation
Bi-atrial enlargement :

 Biatrial enlargement is diagnosed when criteria for both

right and left atrial enlargement are present on the same
ECG.
 It causes deformation of the P wave morphology and axis
Premature atrial contraction (PACs) :

They are beats not originating from the sinus node but the originate from the
atria themselves or from the AV node and this can be known by the duration
of the PR interval :
• If the PR interval is less than 0.12 sec or 120 mSec then its originating from
the AV node
• If the Pr interval is more than 0.12 sec or 120 mSec then its originating
from the atria (right or left)
• If the focus is near the SA node it will give a P wave similar to the sinus
beat
• They cause depolarization of the ventricles causing cardiac contractions
• They are followed by a compensatory pause as the cardiac tissue remain in
the refractory period resisting further depolarization
• They are sporadic and usually asymptomatic and occur in normal individuals
but may indicate irritable myocardium due to ischemia or certain drugs
Multifocal atrial tachycardia :

 It is closely related to PACs but they are repeated from

different foci giving different P waves morphologies and axes
with different PR intervals according to their origin whether
from the AV node itself or from the atria and how close they
are from the AV node and
 At least 3 different P`s morphology are required for diagnosis
 They will depolarize the ventricles causing ventricular
contractions but in irregular fashion with a heart rate ranging
from 100-250
 It is commonly caused by magnesium deficiency and are very
common in COPD patients due to atrial distension and
hypoxia
Inverted T waves :

 P-wave inversion in the inferior leads indicates a non-sinus

origin of the P waves
 When the PR interval is < 120 ms, the origin is in the AV
junction (junctional rhythm)
 When the PR interval is ≥ 120 ms, the origin is within the
atria (ectopic atrial rhythm)
 The heart rate is regular but not sinus
 Usually between 100-150
 Atrial disease due to ischemia and distention are the most
common causes
Abnormalities of the PR
segment and interval
Abnormalities of the QRS
complex
Abnormalities of the ST
segment and the T waves
Abnormalities of the QT
interval
Abnormalities of the rhythm
Section E :

ECG INTERPRETATION IN STEPS

: Section F

EXAMPLES ,EXAMPLES AND EXAMPLES