Medical uses[edit]

Twelve-lead ECG of a 26-year-old male with an incomplete RBBB

General symptoms indicating use of electrocardiography include:
Symptoms of myocardial infarction
Symptoms of pulmonary embolism
Cardiac murmurs[5]
Syncope or collapse[5]
Seizures[5]
Perceived cardiac dysrhythmias[5]
It is also used to assess patients with systemic disease, as well as monitoring
during anesthesia and critically ill patients.[5]
Screening for coronary heart disease[edit]
Preventative Services Task Force do not recommend either the ECG or any other ca
rdiac imaging procedure as a routine screening procedure in patients without sym
ptoms and those at low risk for coronary heart disease.[6][7] This is because ov
eruse of the procedure is more likely to supply incorrect supporting evidence fo
r a nonexistent problem than to detect a true problem.[7] Tests that falsely ind
icate the existence of a problem are likely to lead to misdiagnosis, the recomme
ndation of invasive procedures, or overtreatment, and the risks associated with
managing false information are usually more troublesome than not using ECG resul
ts to make a health recommendation in low-risk individuals.[7]
Persons employed in certain critical occupations, such as aircraft pilots,[8] or
in certain environments, such as high altitudes,[9] may be required to have an
ECG as part of a regulatory regime.
Myocardial infarction[edit]
Main article: Electrocardiography in myocardial infarction
Characteristic changes seen on electrocardiography in myocardial infarction is i
ncluded in the WHO criteria as revised in 2000.[10] According to these, a cardia
c troponin rise accompanied by either typical symptoms, pathological Q waves, ST
elevation or depression or coronary intervention are diagnostic of myocardial i
nfarction.
Pulmonary embolism[edit]
Electrocardiogram of a patient with pulmonary embolism showing sinus tachycardia
of approximately 150 beats per minute and right bundle branch block.
In pulmonary embolism, an ECG may show signs of right heart strain or acute cor
pulmonale in cases of large PEs the classic signs are a large S wave in lead I, a
large Q wave in lead III and an inverted T wave in lead III (S1Q3T3).[11] This i
s occasionally (up to 20%) present, but may also occur in other acute lung condi
tions and has, therefore, limited diagnostic value. This S1Q3T3 pattern from acu
te right heart strain is termed the "McGinn-White sign" after the initial descri
bers. The most commonly seen signs in the ECG is sinus tachycardia, right axis d
eviation, and right bundle branch block.[12] Sinus tachycardia was however still
only found in 8 69% of people with PE.[13]
Other patterns of disease[edit]
The following table mentions some pathological patterns that can be seen on elec
trocardiography, followed by possible causes.
Shortened QT interval Hypercalcemia, some drugs, certain genetic abnormalities
, hyperkalemia
Prolonged QT interval Hypocalcemia, some drugs, certain genetic abnormalities
Flattened or inverted T waves Coronary ischemia, hypokalemia, left ventricular
hypertrophy, digoxin effect, some drugs
Hyperacute T waves
Possibly the first manifestation of acute myocardial inf
arction, where T waves become more prominent, symmetrical, and pointed
Peaked T wave, QRS wide, prolonged PR, QT short Hyperkalemia, treat with calcium
chloride, glucose and insulin or dialysis
Prominent U waves
Hypokalemia
Function[edit]
An ECG produces a pattern reflecting the electrical activity of the heart and us

ually requires a trained clinician to interpret it in the context of the signs a

nd symptoms the patient presents with. It can give information regarding the rhy
thm of the heart[14] (whether or not the electrical impulse consistently arises
from the part of the heart where it should and at what rate), whether that impul
se is conducted normally throughout the heart, or whether any part of the heart
is contributing more or less than expected to the electrical activity of the hea
rt. It can also give information regarding the balance of salts (electrolytes) i
n the blood (e.g. hyperkalaemia) or even reveal problems with sodium channels wi
thin the heart muscle cells (Brugada syndrome).[15] Modern ECG machines often in
clude analysis software that attempts to interpret the pattern but the diagnoses
this produces may not always be accurate.[16]
It is one of the key tests performed when a heart attack (myocardial infarction
or MI) is suspected; the ECG can identify whether the heart muscle has been dama
ged in specific areas, though not all areas of the heart are covered.[17] The EC
G cannot reliably measure the pumping ability of the heart, for which ultrasound
-based (echocardiography) or nuclear medicine tests are used. It is possible for
a human or other animal to be in cardiac arrest, but still have a normal ECG si
gnal (a condition known as pulseless electrical activity).
Principles[edit]
Tab electrode using silver/silver chloride sensing to detect a trace of voltage.
[18]
The ECG device detects and amplifies the tiny electrical changes on the skin tha
t are caused when the heart muscle depolarizes during each heartbeat. At rest, e
ach heart muscle cell has a negative charge, called the membrane potential, acro
ss its cell membrane. Decreasing this negative charge toward zero, via the influ
x of the positive cations, Na+ and Ca++, is called depolarization, which activat
es the mechanisms in the cell that cause it to contract. During each heartbeat,
a healthy heart will have an orderly progression of a wave of depolarisation tha
t is triggered by the cells in the sinoatrial node, spreads out through the atri
um, passes through the atrioventricular node and then spreads all over the ventr
icles. This is detected as tiny rises and falls in the voltage between two elect
rodes placed either side of the heart, which is displayed as a wavy line either
on a screen or on paper. This display indicates the overall rhythm of the heart
and weaknesses in different parts of the heart muscle.
Usually, more than two electrodes are used, and they can be combined into a numb
er of pairs (For example: left arm (LA), right arm (RA), and left leg (LL) elect
rodes form the three pairs LA+RA, LA+LL, and RA+LL). The output from each pair i
s known as a lead. Each lead looks at the heart from a different angle. Differen
t types of ECGs can be referred to by the number of leads that are recorded, for
example 3-lead, 5-lead, or 12-lead ECGs (sometimes simply "a 12-lead"). A 12-le
ad ECG is one in which 12 different electrical signals are recorded at approxima
tely the same time and will often be used as a one-off recording of an ECG, trad
itionally printed out as a paper copy. Three- and 5-lead ECGs tend to be monitor
ed continuously and viewed only on the screen of an appropriate monitoring devic
e, for example during an operation or whilst being transported in an ambulance.
There may or may not be any permanent record of a 3- or 5-lead ECG, depending on
the equipment used.
ECG graph paper[edit]
One second of ECG graph paper
The output of an ECG recorder is a graph (or sometimes several graphs, represent
ing each of the leads) with time represented on the x-axis and voltage represent
ed on the y-axis. A dedicated ECG machine would usually print onto graph paper t
hat has a background pattern of 1-millimeter squares (often in red or green), wi
th bold divisions every 5 mm in both vertical and horizontal directions.
It is possible to change the output of most ECG devices but it is standard to re
present each mV on the y axis as 1 cm and each second as 25 mm on the x-axis (th
at is a paper speed of 25 mm/s). Faster paper speeds can be used, for example, t
o resolve finer detail in the ECG. At a paper speed of 25 mm/s, one small block

of ECG paper translates into 40 ms. Five small blocks make up one large block, w
hich translates into 200 ms. Hence, there are five large blocks per second. A ca
libration signal may be included with a record. A standard signal of 1 mV must m
ove the stylus vertically 1 cm, that is, two large squares on ECG paper.
Layout[edit]
By definition, a 12-lead ECG will show a short segment of the recording of each
of the twelve leads. This is often arranged in a grid of four columns by three r
ows, the first column being the limb leads (I,II, and III), the second column th
e augmented limb leads (aVR, aVL, and aVF), and the last two columns being the c
hest leads (V1-V6). It is usually possible to change this layout, so it is vital
to check the labels to see which lead is represented. Each column will usually
record the same moment in time for the three leads and then the recording will s
witch to the next column, which will record the heart beats after that point. It
is possible for the heart rhythm to change between the columns of leads.
Each of these segments is short, perhaps one to three heart beats only, dependin
g on the heart rate, and it can be difficult to analyse any heart rhythm that sh
ows changes between heart beats. To help with the analysis, some ECG machines wi
ll print one or two "rhythm strips" as well along the bottom of the ECG paper. T
his will usually be lead II (which shows the electrical signal from the atrium,
the P-wave, well) and shows the rhythm for the whole time the ECG was recorded (
usually 5 6 sec). It is usually possible to set the machine to print a number of l
eads continuously if further information regarding the rhythm is required.
The term "rhythm strip" may also refer to the whole printout from a continuous m
onitoring system, which may show only one lead and is either initiated by a clin
ician or in response to an alarm or event.
Artifacts[edit]
The electrocardiogram, an important and basic diagnostic proof can even confuse
a diagnosis due to a wrong interpretation. It has been previously reviewed the m
echanisms behind equipment-related ECG artifacts. A good knowledge about the bas
ic principles of ECG can be very valuable to solve these cases. For example due
to Parkinson disease.[19]
Leads[edit]
Illustration depicting lead placement during electrocardiography
The term "lead" in electrocardiography causes much confusion because it is used
to refer to two different things. In accordance with common parlance, the word l
ead may be used to refer to the electrical cable attaching the electrodes to the
ECG recorder. As such, it may be acceptable to refer to the "left arm lead" as
the electrode (and its cable) that should be attached at or near the left arm. U
sually, 10 of these electrodes are standard in a "12-lead" ECG.
Alternatively (and some would say properly, in the context of electrocardiograph
y), the word lead may refer to the tracing of the voltage difference between two
of the electrodes and is what is actually produced by the ECG recorder. Each wi
ll have a specific name. For example "lead I" is the voltage between the right a
rm electrode and the left arm electrode, whereas "Lead II" is the voltage betwee
n the right arm and the left leg. (This rapidly becomes more complex as one of t
he "electrodes" may in fact be a composite of the electrical signal from a combi
nation of the other electrodes). Twelve of this type of lead form a "12-lead" EC
G.
To cause additional confusion, the term "limb leads" usually refers to the traci
ngs from leads I, II, and III rather than the electrodes attached to the limbs.
Placement of electrodes[edit]
Ten electrodes are used for a 12-lead ECG. The electrodes usually consist of a c
onducting gel, embedded in the middle of a self-adhesive pad onto which cables c
lip. Sometimes the gel also forms the adhesive.[20] They are labeled and placed
on the patient's body as follows:[21][22]
Proper placement of the limb electrodes, color-coded as recommended by the Ameri
can Heart Association (a different colour scheme is used in Europe): The limb el
ectrodes can be far down on the limbs or close to the hips/shoulders, but they m

ust be even (left vs right).[23]

* When exercise stress tests are performed, limb leads may be placed on the trun
k to avoid artifacts while ambulatory (arm leads moved subclavicularly and leg l
eads medial to and above the iliac crest).
Placement of the precordial leads
12 leads
Electrode label (in the USA)
Electrode placement
RA
On the right arm, avoiding thick muscle.
LA
In the same location where RA was placed, but on the left arm.
RL
On the right leg, lateral calf muscle.
LL
In the same location where RL was placed, but on the left leg.
V1
In the fourth intercostal space (between ribs 4 and 5) just to the right
of the sternum (breastbone).
V2
In the fourth intercostal space (between ribs 4 and 5) just to the left
of the sternum.
V3
Between leads V2 and V4.
V4
In the fifth intercostal space (between ribs 5 and 6) in the mid-clavicu
lar line.
V5
Horizontally even with V4, in the left anterior axillary line.
V6
Horizontally even with V4 and V5 in the midaxillary line.
Additional electrodes[edit]
The classical 12-lead ECG can be extended in a number of ways in an attempt to i
mprove its sensitivity in detecting myocardial infarction involving territories
not normally "seen" well. This includes an rV4 lead, which uses the equivalent l
andmarks to the V4 but on the right side of the chest wall (used in paediatric p
atients under 5 years of age due to the dominance of the right ventricle in this
age group[24]) and extending the chest leads onto the back with a V7, V8 and V9
.
The Lewis lead or S5 has the LA electrode placed in the second intercostal space
to the right of the sternum with the RA at the fourth intercostal space. It is
read as lead I and is supposed to demonstrate atrial activity much better to aid
in identification of atrial flutter or broad-complex tachycardia.
A posterior ECG can aid in the diagnosis of a posterior myocardial infarction. T
his is performed by the addition of leads V7, V8 and V9 extending around the lef
t chest wall toward the back.
Limb leads[edit]
In both the 5- and 12-lead configurations, leads I, II and III are called limb l
eads. The electrodes that form these signals are located on the limbs one on each
arm and one on the left leg.[25][26][27] The limb leads form the points of what
is known as Einthoven's triangle.[28]
Lead I is the voltage between the (positive) left arm (LA) electrode and right a
rm (RA) electrode:
I = LA - RA
Lead II is the voltage between the (positive) left leg (LL) electrode and the ri
ght arm (RA) electrode:
II = LL - RA
Lead III is the voltage between the (positive) left leg (LL) electrode and the l
eft arm (LA) electrode:
III = LL - LA
Simplified electrocardiograph sensors designed for teaching purposes, e.g. at hi
gh-school level, are in general limited to three arm electrodes serving similar
purposes.[29]
Unipolar vs. bipolar leads[edit]
The two types of leads are unipolar and bipolar. Bipolar leads have one positive
and one negative pole.[30] In a 12-lead ECG, the limb leads (I, II and III) are

bipolar leads. Unipolar leads also have two poles, as a voltage is measured; ho
wever, the negative pole is a composite pole (Wilson's central terminal, or WCT)
made up of signals from multiple other electrodes.[31] In a 12-lead ECG, all le
ads except the limb leads are unipolar (aVR, aVL, aVF, V1, V2, V3, V4, V5, and V
6).
Wilson's central terminal VW is produced by connecting the electrodes RA, LA, an
d LL together, via a simple resistive network, to give an average potential acro
ss the body, which approximates the potential at infinity (i.e. zero):
V_W = \frac{1}{3}(RA+LA+LL)
Augmented limb leads[edit]
Leads aVR, aVL, and aVF are augmented limb leads (after their inventor Dr. Emanu
el Goldberger known collectively as the Goldberger's leads). They are derived fr
om the same three electrodes as leads I, II, and III. However, they view the hea
rt from different angles (or vectors) because the negative electrode for these l
eads is a modification of Wilson's central terminal. This zeroes out the negativ
e electrode and allows the positive electrode to become the "exploring electrode
". This is possible because Einthoven's Law states that I + (-II) + III = 0. The
equation can also be written I + III = II. It is written this way (instead of I
- II + III = 0) because Einthoven reversed the polarity of lead II in Einthoven
's triangle, possibly because he liked to view upright QRS complexes. Wilson's c
entral terminal paved the way for the development of the augmented limb leads aV
R, aVL, aVF and the precordial leads V1, V2, V3, V4, V5 and V6.
Lead augmented vector right (aVR)' has the positive electrode (white) on the rig
ht arm. The negative electrode is a combination of the left arm (black) electrod
e and the left leg (red) electrode, which "augments" the signal strength of the
positive electrode on the right arm:
aVR = RA - \frac{1}{2} (LA + LL) = \frac 32 (RA - V_W)
Lead augmented vector left (aVL) has the positive (black) electrode on the left
arm. The negative electrode is a combination of the right arm (white) electrode
and the left leg (red) electrode, which "augments" the signal strength of the po
sitive electrode on the left arm:
aVL = LA - \frac{1}{2} (RA + LL) = \frac 32 (LA - V_W)
Lead augmented vector foot (aVF) has the positive (red) electrode on the left le
g. The negative electrode is a combination of the right arm (white) electrode an
d the left arm (black) electrode, which "augments" the signal of the positive el
ectrode on the left leg:
aVF = LL - \frac{1}{2} (RA + LA) = \frac 32 (LL - V_W)
The augmented limb leads aVR, aVL, and aVF are amplified in this way because the
signal is too small to be useful when the negative electrode is Wilson's centra
l terminal. Together with leads I, II, and III, augmented limb leads aVR, aVL, a
nd aVF form the basis of the hexaxial reference system, which is used to calcula
te the heart's electrical axis in the frontal plane. The aVR, aVL, and aVF leads
can also be represented using the I and II limb leads:
\begin{align}
aVR &= -\frac{I + II}{2}\\
aVL &= I - \frac{II}{2}\\
aVF &= II - \frac{I}{2}
\end{align}
Precordial leads[edit]
The electrodes for the precordial leads (V1, V2, V3, V4, V5 and V6) are placed d
irectly on the chest. Because of their close proximity to the heart, they do not
require augmentation. Wilson's central terminal is used for the negative electr
ode, and these leads are considered to be unipolar (recall that Wilson's central
terminal is the average of the three limb leads. This approximates common, or a
verage, potential over the body). The precordial leads view the heart's electric
al activity in the so-called horizontal plane. The heart's electrical axis in th

e horizontal plane is referred to as the Z axis.

Esophageal lead[edit]
? lead story: Filtered esophageal left heart electrogram.
The filtered esophageal left heart electrogram is a semi-invasive method. This t
echnique is able to provide additional marker from the left atrium and the left
ventricle.
The filtered bipolar esophageal left atrial electrogram (LAE) recording, in comb
ination with the surface ECG can be of advantage in all situations requiring dou
btless recognition of the atrial activities. With this additional left atrial mar
ker channel the atrial activities can easily be recognized even if they are super
imposed by the QRS complex. Thus, LAE recording can be utilized, for example, to
quickly differentiate tachycardias and extrasystolies and to diagnose DDD pacem
aker malfunctions. As a special advantage in atrio-biventricular and conventiona
l AV block pacing, the esophageal left atrial electrogram recoding enables measu
rement of interatrial conduction intervals, which are the major determinants of
the optimal AV delays in VDD and DDD pacing.
Compared to the surface ECG, the filtered bipolar esophageal left ventricular el
ectrogram allows a more direct determination of the extent of cardiac desynchron
ization in heart failure patients. Thus, the esophageal left ventricular conduct
ion delay (LVCDE) could be used as an additional marker of interventricular dyss
ynchrony to justify implantation of biventricular pacing systems and to guide th
e positioning of the left ventricular electrode.
The recording of the esophageal left heart electrograms requires a bipolar esoph
ageal electrode. For example, the TOslim (Osypka AG, Rheinfelden, Germany) can b
e used. It has to be applied perorally or transnasally either with or without an
y mild sedation. To eliminate artifacts in the esophageal left atrial electrogra
m and to improve the differentiation between the left atrial deflection and the
ventricular complex, high-pass filtering is recommended. Best results can be obt
ained using Butterworth high-pass filter technique (for example: through the DC
input of a standard ECG recorder in combination with the Rostockfilter (Osypka A
G, Rheinfelden, Germany) or by using the esophageal electrogram option of the Bi
otronik ICS 3000 programmer. In this case, no further equipment is needed. [32]
Waves and intervals[edit]
Schematic representation of normal ECG
Animation of a normal ECG wave
Detail of the QRS complex, showing ventricular activation time (VAT) and amplitu
de
Upper limit of normal QT interval, corrected for heart rate according to Bazett'
s formula,[33] Fridericia's formula[34] and subtracting 0.02 s from QT for every
10 bpm increase in heart rate.[35] Up to 0.42 s (= 420 ms) is chosen as normal
QTc of QTB and QTF in this diagram.
A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave, a Q
RS complex, a T wave, and a U wave, which is normally invisible in 50 to 75% of
ECGs because it is hidden by the T wave and upcoming new P wave.[36] The baselin
e of the electrocardiogram (the flat horizontal segments) is measured as the por
tion of the tracing following the T wave and preceding the next P wave and the s
egment between the P wave and the following QRS complex (PR segment). In a norma
l healthy heart, the baseline is equivalent to the isoelectric line (0 mV) and r
epresents the periods in the cardiac cycle when there are no currents towards ei
ther the positive or negative ends of the ECG leads. However, in a diseased hear
t, the baseline may be depressed (e.g., cardiac ischaemia) or elevated (e.g., my
ocardial infarction) relative to the isoelectric line due to injury currents dur
ing the TP and PR intervals when the ventricles are at rest. The ST segment typi
cally remains close to the isoelectric line as this is the period when the ventr
icles are fully depolarised and thus no currents can be in the ECG leads. Since
most ECG recordings do not indicate where the 0 mV line is, baseline depression

often gives the appearance of an elevation of the ST segment and conversely base
line elevation gives the appearance of depression of the ST segment.[37]
Feature Description
Duration
RR interval
The interval between an R wave and the next R wave; normal resti
ng heart rate is between 60 and 100 bpm.
0.6 to 1.2 s
P wave During normal atrial depolarization, the main electrical vector is direc
ted from the SA node towards the AV node and spreads from the right atrium to th
e left atrium. This turns into the P wave on the ECG. 80ms
PR interval
The PR interval is measured from the beginning of the P wave to
the beginning of the QRS complex. The PR interval reflects the time the electric
al impulse takes to travel from the sinus node through the AV node and entering
the ventricles. The PR interval is, therefore, a good estimate of AV node functi
on.
120 to 200 ms
PR segment
The PR segment connects the P wave and the QRS complex. The impu
lse vector is from the AV node to the Bundle of His to the bundle branches and t
hen to the Purkinje fibers. This electrical activity does not produce a contract
ion directly and is merely traveling down towards the ventricles, and this shows
up flat on the ECG. The PR interval is more clinically relevant.
50 to 12
0 ms
QRS complex
The QRS complex reflects the rapid depolarization of the right a
nd left ventricles. The ventricles have a large muscle mass compared to the atri
a, so the QRS complex usually has a much larger amplitude than the P-wave.
80 to 100 ms
J-point The point at which the QRS complex finishes and the ST segment begins. I
t is used to measure the degree of ST elevation or depression present. N/A
ST segment
The ST segment connects the QRS complex and the T wave. The ST s
egment represents the period when the ventricles are depolarized. It is isoelect
ric.
80 to 120 ms
T wave The T wave represents the repolarization (or recovery) of the ventricles
. The interval from the beginning of the QRS complex to the apex of the T wave i
s referred to as the absolute refractory period. The last half of the T wave is
referred to as the relative refractory period (or vulnerable period). 160 ms
ST interval
The ST interval is measured from the J point to the end of the T
wave. 320 ms
QT interval
The QT interval is measured from the beginning of the QRS comple
x to the end of the T wave. A prolonged QT interval is a risk factor for ventric
ular tachyarrhythmias and sudden death. It varies with heart rate and, for clini
cal relevance, requires a correction for this, giving the QTc. Up to 420 ms in
heart rate of 60 bpm
U wave The U wave is hypothesized to be caused by the repolarization of the int
erventricular septum. It normally has a low amplitude, and even more often is co
mpletely absent. It always follows the T wave, and also follows the same directi
on in amplitude. If it is too prominent, suspect hypokalemia, hypercalcemia or h
yperthyroidism.[38]
J wave The J wave, elevated J-point or Osborn wave appears as a late delta wave
following the QRS or as a small secondary R wave. It is considered pathognomoni
c of hypothermia or hypercalcemia.[39]
Originally, four deflections were noted, but after the mathematical correction f
or artifacts introduced by early amplifiers, a fifth deflection was discovered.
Einthoven chose the letters P, Q, R, S, and T to identify the tracing that was s
uperimposed over the uncorrected labeled A, B, C, and D.[40]
In intracardiac electrocardiograms, such as can be acquired from pacemaker senso
rs, an additional wave can be seen, the H deflection, which reflects the depolar
ization of the bundle of His.[41] The H-V interval, in turn, is the duration fro
m the beginning of the H deflection to the earliest onset of ventricular depolar
ization recorded in any lead.[42]
Vectors and views[edit]
Graphic showing the relationship between positive electrodes, depolarization wav
efronts (or mean electrical vectors), and complexes displayed on the ECG

Interpretation of the ECG relies on the idea that different leads (meaning the E
CG leads I, II, III, aVR, aVL, aVF and the chest leads) "view" the heart from di
fferent angles. This has two benefits. First, leads that are showing problems (f
or example ST segment elevation) can be used to infer which region of the heart
is affected. Second, the overall direction of travel of the wave of depolarisati
on can also be inferred, which can reveal other problems. This is termed the car
diac axis . Determination of the cardiac axis relies on the concept of a vector,
which describes the motion of the depolarisation wave. This vector can then be
described in terms of its components in relation to the direction of the lead co
nsidered. One component will be in the direction of the lead and this will be re
vealed in the behaviour of the QRS complex and one component will be at 90 to thi
s (which will not). Any net positive deflection of the QRS complex (i.e., height
of the R-wave minus depth of the S-wave) suggests the wave of depolarisation is
spreading through the heart in a direction that has some component (of the vect
or) in the same direction as the lead in question.
Axis[edit]
Diagram showing how the polarity of the QRS complex in leads I, II, and III can
be used to estimate the heart's electrical axis in the frontal plane
The heart's electrical axis refers to the general direction of the heart's depol
arization wavefront (or mean electrical vector) in the frontal plane. With a hea
lthy conducting system, the cardiac axis is related to where the major muscle bu
lk of the heart lies. Under normal circumstances, this is the left ventricle, wi
th some contribution from the right ventricle. It is usually oriented in a right
shoulder to left leg direction, which corresponds to the left inferior quadrant
of the hexaxial reference system, although -30 to +90 is considered to be normal.
If the left ventricle increases its activity or bulk, then there is said to be
"left axis deviation" as the axis swings around to the left beyond -30; however,
in conditions wherein the right ventricle is strained or hypertrophied, then the
axis swings around beyond +90 and "right axis deviation" is said to exist. Disor
ders of the conduction system of the heart can disturb the electrical axis witho
ut necessarily reflecting changes in muscle bulk.
Normal -30 to 90
Normal Normal
Left axis deviation
-30 to -90
May indicate left anterior fascicular bl
ock or Q waves from inferior MI.
Left axis deviation is considered normal
in pregnant women and those with emphysema.
Right axis deviation
+90 to +180 May indicate left posterior fascicular b
lock, Q waves from high lateral MI, or a right ventricular strain pattern
Right deviation is considered normal in children and is a standard effect of dex
trocardia.
Extreme right axis deviation
+180 to -90 Is rare, and considered an 'elec
trical no-man's land'
The hexaxial reference system showing the orientation of each lead: For example,
if the bulk of heart muscle is oriented at +60 degrees with respect to the SA n
ode, lead II will show the greatest deflection and aVL the least.
In the setting of right bundle branch block, right or left axis deviation may in
dicate bifascicular block.
Lead groups[edit]
Of the 12 leads in total, each records the electrical activity of the heart from
a different perspective, which also correlates to different anatomical areas of
the heart for the purpose of identifying acute coronary ischemia or injury. Two
leads that look at neighbouring anatomical areas of the heart are said to be co
ntiguous. The relevance of this is in determining whether an abnormality on the
ECG is likely to represent true disease or a spurious finding.
Diagram showing the contiguous leads in the same color
Category
Color on chart Leads Activity
Inferior leads' Yellow Leads II, III and aVF Look at electrical activity from
the vantage point of the inferior surface (diaphragmatic surface of heart)

Lateral leads Green I, aVL, V5 and V6

Look at the electrical activity
from the vantage point of the lateral wall of left ventricle
The positive electrode for leads I and aVL should be located distally on the lef
t arm and, because of which, leads I and aVL are sometimes referred to as the hi
gh lateral leads.
Because the positive electrodes for leads V5 and V6 are on the patient's chest,
they are sometimes referred to as the low lateral leads.
Septal leads
Orange V1 and V2
Look at electrical activity from the van
tage point of the septal surface of the heart (interventricular septum)
Anterior leads Blue
V3 and V4
Look at electrical activity from the van
tage point of the anterior wall of the right and left ventricles (Sternocostal s
urface of heart)
In addition, any two precordial leads next to one another are considered to be c
ontiguous. For example, though V4 is an anterior lead and V5 is a lateral lead,
they are contiguous because they are next to one another. A common saying to rem
ember the contiguous leads is "I see all leads" (inferior, septal, anterior and
lateral).
Wiggers diagram, showing a normal ECG curve synchronized with other major events
during the cardiac cycle
Lead aVR offers no specific view of the left ventricle. Rather, it views the ins
ide of the endocardial wall to the surface of the right atrium, from its perspec
tive on the right shoulder.
Filter selection[edit]
Modern ECG monitors offer multiple filters for signal processing. The most commo
n settings are monitor mode and diagnostic mode. In monitor mode, the low-freque
ncy filter (also called the high-pass filter because signals above the threshold
are allowed to pass) is set at either 0.5 Hz or 1 Hz and the high-frequency fil
ter (also called the low-pass filter because signals below the threshold are all
owed to pass) is set at 40 Hz. This limits artifacts for routine cardiac rhythm
monitoring. The high-pass filter helps reduce wandering baseline and the low-pas
s filter helps reduce 50- or 60-Hz power line noise (the power line network freq
uency differs between 50 and 60 Hz in different countries). In diagnostic mode,
the high-pass filter is set at 0.05 Hz, which allows accurate ST segments to be
recorded. The low-pass filter is set to 40, 100, or 150 Hz. As a consequence, th
e monitor mode ECG display is more filtered than diagnostic mode, because its pa
ssband is narrower.[43]
Electrocardiogram heterogeneity[edit]
ECG heterogeneity is a measurement of the amount of variance between one ECG wav
eform and the next. This heterogeneity can be measured by placing multiple ECG e
lectrodes on the chest and then computing the variance in waveform morphology ac
ross the signals obtained from these electrodes. Recent research suggests ECG he
terogeneity often precedes dangerous cardiac arrhythmias.
In the future, implantable devices may be programmed to measure and track hetero
geneity. These devices have potential to help ward off arrhythmias by stimulatin
g nerves such as the vagus nerve, delivering drugs such as beta-blockers and, if
necessary, defibrillating the heart.[44]
Rhythm strip[edit]
Although multiple leads, and thus multiple electrical vectors, are commonly used
in unison to gain diagnostic and therapeutic insight into cardiac status, monit
oring one lead, referred to as a rhythm strip, can be useful to trend cardiac fu
nction in terms of heart rate, regularity, pauses, and basic rhythm.
History[edit]
The etymology of the word is derived from the Greek electro, because it is relat
ed to electrical activity, kardio, Greek for heart, and graph, a Greek root mean
ing "to write".
Alexander Muirhead is reported to have attached wires to a feverish patient's wr
ist to obtain a record of the patient's heartbeat while studying for his Doctor
of Science (in electricity) in 1872 at St Bartholomew's Hospital.[45] This activ
ity was directly recorded and visualized using a Lippmann capillary electrometer

by the British physiologist John Burdon Sanderson.[46] The first to systematica

lly approach the heart from an electrical point of view was Augustus Waller, wor
king in St Mary's Hospital in Paddington, London.[47] His electrocardiograph mac
hine consisted of a Lippmann capillary electrometer fixed to a projector. The tr
ace from the heartbeat was projected onto a photographic plate that was itself f
ixed to a toy train. This allowed a heartbeat to be recorded in real time. In 19
11 he still saw little clinical application for his work.
An early commercial ECG device (1911)
An initial breakthrough came when Willem Einthoven, working in Leiden, the Nethe
rlands, used the string galvanometer he invented in 1901.[48] This device was mu
ch more sensitive than both the capillary electrometer Waller used and the strin
g galvanometer that had been invented separately in 1897 by the French engineer
Clment Ader.[49] Rather than using today's self-adhesive electrodes Einthoven's s
ubjects would immerse each of their limbs into containers of salt solutions from
which the ECG was recorded.
Einthoven assigned the letters P, Q, R, S, and T to the various deflections,[40]
and described the electrocardiographic features of a number of cardiovascular d
isorders. In 1924, he was awarded the Nobel Prize in Medicine for his discovery.
[50]
Though the basic principles of that era are still in use today, many advances in
electrocardiography have been made over the years. The instrumentation, for exa
mple, has evolved from a cumbersome laboratory apparatus to compact electronic s
ystems that often include computerized interpretation of the electrocardiogram.[
51]
Fetal electrocardiography[edit]
Fetal electrocardiography records the electrical activity of a fetus, and when p
erformed as a part of monitoring in childbirth, involves a single electrode bein
g passed through the woman's cervix and attached to the baby's scalp.[52] Accord
ing to a Cochrane review, monitoring the fetus using ECG plus cardiotocography (
CTG) resulted in fewer instances of fetal scalp blood testing and less surgical
assistance with the birth, compared to CTG alone.[52] There was no difference in
the number of Caesarean deliveries and little to suggest the babies were in bet
ter condition at birth.[52]