Electrocardiogram Introduction

The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical
activity of the heart in exquisite detail. Interpretation of these details allows diagnosis of a wide range of
heart conditions. These conditions can vary from minor to life threatening.

The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch
Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG.

The ECG has evolved over the years.

• The standard 12-lead ECG that is used throughout the world was introduced in 1942.

• It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points
of view.

• This is necessary because no single point (or even 2 or 3 points of view) provides a complete
picture of what is going on.

• To fully understand how an ECG reveals useful information about the condition of your heart
requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the
function) of the heart.

Basic Anatomy of the Heart

The heart is a 4-chambered muscle whose function is to pump blood throughout the body.

• The heart is really 2 "half hearts," the right heart and the left heart, which beat simultaneously.

• Each of these 2 sides has 2 chambers: a smaller upper chamber called the atrium (together,
the 2 are called atria), and a larger lower chamber called the ventricle.

• Thus, the 4 chambers of the heart are called the right atrium, right ventricle, left atrium, and left
ventricle.

This sequence also represents the direction of blood flow through the heart.

• The right atrium receives blood that has completed a tour around the body and is depleted of
oxygen and other nutrients. This blood returns via 2 large veins: the superior vena cava returning
blood from the head, neck, arms, and upper portions of the chest, and the inferior vena cava
returning blood from the remainder of the body.

• The right atrium pumps this blood into the right ventricle, which, a fraction of a second later,
pumps the blood into the blood vessels of the lungs.
 • The lungs serve 2 functions: to oxygenate the blood by exposing it to the air you breathe in
(which is 20% oxygen), and to eliminate the carbon dioxide that has accumulated in the blood as a
result of the body's many metabolic functions.

• Having passed through the lungs, the blood enters the left atrium, which pumps it into the left
ventricle.

• The left ventricle then pumps the blood back into the circulatory system of blood vessels
(arteries and veins). The blood leaves the left ventricle via the aorta, the largest artery in the body.
Because the left ventricle has to exert enough pressure to keep the blood moving throughout all the
blood vessels of the body, it is a powerful pump. It is the pressure generated by the left ventricle that
gets measured when you have your blood pressure checked.

The heart, like all tissues in the body, requires oxygen to function. Indeed, it is the only muscle in the
body that never rests. Thus, the heart has reserved for itself its own blood supply.

• This blood flows to the heart muscle through a group of arteries that begins less than one-half
inch from where the aorta begins. These are known as the coronary arteries. These arteries deliver
oxygen to both the heart muscle and the nerves of the heart.

• When something happens so that the flow of blood through a coronary artery gets interrupted,
then the part of the heart muscle supplied by that artery begins to die. This is called coronary heart
disease, or coronary artery disease. If this condition is not stopped, the heart itself starts to lose its
strength to pump blood, a condition known as heart failure.

• When the interruption of coronary blood flow lasts only a few minutes, the symptoms are called
angina, and there is no permanent damage to the heart. When the interruption lasts longer, that part
of the heart muscle dies. This is referred to as a heart attack (myocardial infarction).

Nerves of the heart: The heart's function is so important to the body that it has its own electrical system
to keep it running independently of the rest of the body's nervous system.

• Even in cases of severe brain damage, the heart often beats normally.

• An extensive network of nerves runs throughout all 4 chambers of the heart. Electrical impulses
course through these nerves to trigger the chambers to contract with perfectly synchronized timing
much like the distributor and spark plugs of a car make sure that an engine's pistons fire in the right
sequence.

• The ECG records this electrical activity and depicts it as a series of graph-like tracings, or
waves. The shapes and frequencies of these tracings reveal abnormalities in the heart's anatomy or
function.

Before describing the ECG itself, let's take a look at the heart's electrical system.

Heart Function and the ECG

The heart normally beats between 60 and 100 times per minute, with many normal variations. For
example, athletes at rest have slower heart rates than most people. This rate is set by a small
collection of specialized heart cells called the sinoatrial (SA) or sinus node.

Located in the right atrium, the sinus node is the heart's "natural pacemaker."

• It has "automaticity," meaning it discharges all by itself without control from the brain.

• Two events occur with each discharge: (1) both atria contract, and (2) an electrical impulse
travels through the atria to reach another area of the heart called the atrioventricular (AV) node,
which lies in the wall between the 2 ventricles.

• The AV node serves as a relay point to further propagate the electrical impulse.

• From the AV node, an electrical wave travels to both ventricles, causing them to contract and
pump blood.

• The normal delay between the contraction of the atria and of the ventricles is 0.12 to 0.20
seconds. This delay is perfectly timed to account for the physical passage of the blood from the
atrium to the ventricle. Intervals shorter or longer than this range indicate possible problems.

The ECG records the electrical activity that results when the heart muscle cells in the atria and
ventricles contract.

• Atrial contractions (both right and left) show up as the P wave.

• Ventricular contractions (both right and left) show as a series of 3 waves, Q-R-S, known as the
QRS complex.

• The third and last common wave in an ECG is the T wave. This reflects the electrical activity
produced when the ventricles are recharging for the next contraction (repolarizing).

• Interestingly, the letters P, Q, R, S, and T are not abbreviations for any actual words but were
chosen many years ago for their position in the middle of the alphabet.

• The electrical activity results in P, QRS, and T waves that have a myriad of sizes and shapes.
When viewed from multiple anatomic-electric perspectives (that is, leads), these waves can show a
wide range of abnormalities of both the electrical conduction system and the muscle tissue of the
heart's 4 pumping chambers

What You Can Expect During an ECG

Few procedures in medicine are easier than an ECG.

• You will lie down quietly on a bed or stretcher.

• A technician (or sometimes a nurse, doctor, or other medical professional) will place 6 small
adhesive electrode pads across your chest from your lower breast bone (sternum) to an area below
 your left armpit. Other pads will be placed on each of your arms and legs. Insulated wires will
connect each of these 10 pads to the ECG machine.

• Once these wires, called "leads," are attached, the ECG records a few heartbeats on a single
sheet of graph paper.

Each heartbeat produces a set of P-QRS-T waves.

• This set of waves, in turn, is recorded and analyzed from each of 12 points of view.

• Six of these points of view are the locations of the 6 pads placed across your chest. These are
called V1, V2, V3, V4, V5, and V6 (pronounced Vee One, Vee Two, and so on).

• The other points of view represent combinations of the pads placed on the arms and legs.
These are called I, II, III , aVR, aVL, and aVF.

• The interpretation of the waves produced by each of these 12 views provides valuable
information about the functioning of your heart.

In some circumstances, medical illnesses elsewhere in the body or various drugs (especially in
overdose situations) affect an otherwise healthy heart in ways revealed by diagnostic or suggestive
changes in to the ECG changes.

In addition to the 12-lead ECG, an additional "rhythm strip" may be taken. This represents only one
point of view but is a good way to see important changes that may be occurring over longer periods of
time.

• These may be changes that are hard to interpret or are not even detected in the handful of
heartbeats recorded in the standard 12-lead ECG.

• This is especially useful when the heart is beating slower or faster than normal.

Some people with heart rhythm disorders (arrhythmias) or coronary heart disease have symptoms that
come and go.

• These symptoms may include brief chest pain or angina, palpitations, dizziness, or weakness.

• If you are not having symptoms when you see your health care provider, your ECG result may
be perfectly normal.

• This is a common occurrence, and it is frustrating because your health care provider cannot
properly diagnose or treat your problem until it has been documented on ECG.

If this happens to you, your health care provider will probably recommend ambulatory ECG.

• This is a good way to "catch" and document any temporary or intermittent abnormalities such
as irregular heartbeats.
 • For this test, you are attached to an ECG recording device (sometimes called a Holter monitor)
that records every heartbeat for periods of 24 hours (or longer, if necessary). An alternative method
is to record the heartbeats only intermittently but for a longer period of time, days or weeks.

• Long-term monitoring significantly increases your chances of "catching" any abnormalities on

the ECG, even if they last only a few minutes or seconds

Reasons to Have an ECG

Heart problems can produce a wide array of symptoms.

• Without the benefit of an ECG, it may be impossible to tell whether these symptoms are being
caused by a heart problem or just mimicking one.

• Therefore, unless your symptoms are explained by an illness, injury, or condition known to not
affect the heart, an ECG will generally be done.

Common symptoms that frequently require an ECG include the following:

• Chest pain or discomfort

• Shortness of breath

• Nausea

• Weakness

• Palpitations (rapid or pounding heartbeats or increased awareness of heart beating)

• Anxiety

• Abdominal pain

• Fainting (syncope)

ECG often reveals a problem that is not primarily cardiac in nature. Examples are overdoses of certain
drugs (such as certain antidepressants, cocaine, or amphetamines) or electrolyte abnormalities
(especially potassium).

If you are about to have surgery with general anesthesia, you will have an ECG to detect any latent
(silent) cardiac conditions that might worsen with the stresses of surgery and anesthesia.

People of any age who are in occupations that stress the heart (professional athletes or firefighters, for
example) or involve public safety (commercial airline pilots, train conductors, and bus drivers) require
ECGs as well.

Anyone aged 40 years or older should have an ECG done. This first ECG serves as a screening tool to
detect any cardiac problems and as a baseline for comparison of future ECGs.
A complete list of who should obtain an ECG, called Guidelines for ECG, is published by the Joint
Committee of the AHA/ACC (American Heart Association/American College of Cardiology).

Common Causes of ECG Tracings

If you are having symptoms, the ECG is just one test your health care provider will use in making an
overall evaluation. Your ECG may be completely normal despite the presence of significant heart
disease.

Here's an example: An overweight man who smokes, never exercises, and eats a fatty diet has his
coronary arteries 70% blocked by cholesterol deposits.

• Despite this, during the quiet resting conditions under which most ECGs are performed,
coronary blood flow will be sufficient to give the heart muscle the oxygen it needs. The ECG,
therefore, may be perfectly normal. In these circumstances, a normal ECG would give a false sense
of security that all is well with the heart.

• If this person exercises on a treadmill (or shovels snow, chops wood, digs a hole for a fence, or
performs similar activity), his heart will need to pump twice as much blood to deliver twice as much
oxygen to the muscles of the arms and legs. With 70% blockage of the coronary arteries, the heart
muscle likely will not get the blood flow it needs. This may manifest as fatigue, shortness of breath,
or discomfort in the chest or arms.

• An unsuspecting person may attribute these symptoms to overexertion and will slow down or
stop the exercise and never realize that is heart is producing warning signs. On a treadmill under
continuous ECG monitoring, however, the ECG usually identifies the problem before a full-blown
heart attack has occurred, it is hoped.

In cases of angina, when the blockage is temporary, the telltale ECG changes will be temporary as
well. When a heart attack has occurred, on the other hand, a part of the actual heart muscle has died,
and the ECG changes will be permanent.

• In a heart attack, affected portion(s) of the heart will be electrically silent, and, like a burned-out
light bulb, no longer radiate energy.

• This shows up as changes in the voltages of the ECG, especially of the QRS complex.

For these reasons, it is especially important to go to a hospital emergency department in the early
stages of a heart attack.

• Some people are eligible to receive a medication that rapidly dissolves the coronary artery
blockage.

• This medication works only if it is given within 6 hours after the onset of symptoms.

• Other people are not eligible to receive this medication because of potential complications,
such as bleeding.
Electrical problems within the heart may disrupt the heart's natural pacemaker.

• The extensive electrical network of nerves and nerve centers that coordinate the firing of the 4
chambers is made of living cells that require oxygen every bit as much as the heart muscle. These
cells are subject to malfunction when starved of oxygen by blockage of a coronary artery. When this
occurs, the heart may beat too fast, too slowly, or too irregularly to sustain its normal pumping
function.

• For example, if the coronary artery supplying the sinus node is blocked, the sinus node may
fail. If the failure is partial, the heart rate will slow down. If the failure is complete, then there will be
no activation of the atria, no atrial contraction, and no signal to trigger the AV node. The heart will
stop pumping. This is called cardiac arrest and usually causes death.

Fortunately, the AV node has automaticity of its own. This means that in the absence of a normal
incoming signal from the sinus node, the AV node will fire on its own, but at the slower rate of 35-60
times per minute.

• Depending on the condition of the rest of the heart (the coronary arteries and the valves, for
example), this slower rate may or may not result in symptoms.

• Because a heart so affected loses its ability to speed up when needed, it is generally only a
matter of time before the condition results in noticeable symptoms. This condition, known as sick
sinus syndrome, is one of the more common reasons that people need an artificial pacemaker.

• Sometimes a body's natural pacemaker malfunctions despite an otherwise perfectly healthy

heart. (This is the equivalent to a car engine that doesn't run well because of a spark plug problem.)
This was the situation for Arne Larsson, a Swedish engineer who received the first artificial
pacemaker in 1958. He died in December 2001, aged 86 years, of causes unrelated to his heart.

Sometimes the heart's 2 ventricles beat so rapidly that very little or no blood at all is pumped because
there is not enough time between contractions for the ventricles to fill.

• This dangerous condition is known as ventricular tachycardia if the heartbeat is regular and
ventricular fibrillation if the heartbeat is irregular.

• When this occurs, a well-placed electrical shock across the chest may be life saving.

• The shock, known as defibrillation, neutralizes all the abnormal electric circuits, thus giving the
heart's pacemaker a chance to kick in at a normal rate.

Because the brain and heart cannot survive total loss of blood flow lasting much more than about 10
minutes, it is crucial that the shock be delivered within this time frame. A device called an AED
(automatic external defibrillator) is increasingly being made available in public locations such as large
office buildings, shopping malls, golf courses, and airplanes. For further information, see the American
Heart Association's Questions and Answers about AEDs.
Interpreting the ECG Results

Interpretation of an ECG is no simple matter.

• There are hundreds of patterns to recognize.

• It may be impossible to tell how long an abnormality has been present.

• This issue becomes crucial in an emergency situation when a person has symptoms consistent
with a heart problem and an abnormal ECG.

Some or all of the abnormalities may have been caused by an event long in the past and unrelated to
the current situation.

• Some people are even born with ECG abnormalities.

• This can make it difficult to identify which problems require urgent treatment.

• This is the equivalent of examining a car that has been in both a recent car accident and
accidents in the past. Which dents were caused by which accident?

For these reasons, if you have either a heart condition or an abnormal ECG, you would be wise to keep
a recent copy of your ECG handy in your wallet, purse, or car glove compartment for immediate
availability.

• This way you will be able to provide your baseline ECG to a very grateful emergency care
provider in case you unexpectedly end up in an emergency department, especially in the middle of
the night or far from home.

• A copy of your ECG can be shrunk to credit card size and laminated to be carried in your wallet.
If you have an abnormal ECG or you travel a lot, ask your health care provider about doing this for
you
Media file 1: Rhythm strip showing a normal 12-lead ECG.

Media type: Rhythm Strip

Media file 2: Conducting system of the heart: SA means sinoatrial node. AV means atrioventricular
node. RB and LB mean right and left bundle, respectively, and are the nerves that spread the electric
impulse from the AV node into the ventricles.

Media type: Illustration

Media file 3: Basic P-QRS-T wave sequence: Strip shows a simple sequence where M equals 1.0
millivolts.

Media type: Photo

Media file 4: Location for placement of the 6 precordial leads across the chest around the heart (V1 to
V6).

Media type: Illustration

Media file 5: A cross-section of the heart: The 6 precordial leads showing that P-QRS-T wave shapes
vary with position around the heart.
Media type: Illustration

Media file 6: Rhythm strip of a person who was cardioverted out of ventricular tachycardia by an
electric shock.

Media type: Rhythm Strip

Media file 7: A 12-lead electrocardiogram (ECG) of a person with chest pain. It shows heart attack
(acute inferior wall myocardial infarction). Image courtesy of Vibhuti N Singh, MD, MPH, FACC.

Media type: Rhythm Strip

The ECG works mostly by detecting and amplifying the tiny electrical changes on the skin that are caused when
the heart muscle "depolarises" during each heart beat. At rest, each heart muscle cell has a charge across its outer
wall, or cell membrane. Reducing this charge towards zero is called de-polarisation, which activates 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 that is triggered by the cells in the sinoatrial node, spreads out through the
atrium, passes through "intrinsic conduction pathways" and then spreads all over the ventricles. This is detected as
tiny rises and falls in the voltage between two electrodes 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 2 electrodes are used and they can be combined into a number of pairs. (For example: Left arm
(LA),right arm (RA) and left leg (LL) electrodes form the pairs: LA+RA, LA+LL, RA+LL) The output from each
pair is known as a lead. Each lead is said to look at the heart from a different angle. Different 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-lead ECG is one in which 12 different electrical signals are recorded at approximately
the same time and will often be used as a one-off recording of an ECG, typically printed out as a paper copy. 3-
and 5-lead ECGs tend to be monitored continuously and viewed only on the screen of an appropriate monitoring
device, 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.

It is the best way to measure and diagnose abnormal rhythms of the heart,[2] particularly abnormal rhythms caused
by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by electrolyte
imbalances.[3] In a myocardial infarction (MI), the ECG can identify if the heart muscle has been damaged in
specific areas, though not all areas of the heart are covered.[4] The ECG cannot reliably measure the pumping
ability of the heart, for which ultrasound-based (echocardiography) or nuclear medicine tests are used. It is
possible to be in cardiac arrest with a normal ECG signal (a condition known as pulseless electrical activity).

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 lead 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. There are usually ten of these electrodes in a standard
"12-lead" ECG.

Alternatively (and some would say properly, in the context of electrocardiography) 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 will have a specific name. For example "Lead I" (lead one) is the voltage between the right arm
electrode and the left arm electrode, whereas "Lead II" (lead two) is the voltage between the right limb and the
feet. (This rapidly becomes more complex as one of the "electrodes" may in fact be a composite of the electrical
signal from a combination of the other electrodes. (See later.) Twelve of this type of lead form a "12-lead" ECG

To cause additional confusion the term "limb leads" usually refers to the tracings from leads I, II and III rather
than the electrodes attached to the limbs.

[edit] Placement of electrodes

Ten electrodes are used for a 12-lead ECG. The electrodes usually consist of a conducting gel, embedded in the
middle of a self-adhesive pad onto which cables clip. Sometimes the gel also forms the adhesive.[12] They are
labeled and placed on the patient's body as follows:[13][14]

Proper placement of the limb electrodes, color coded as recommended by the American Heart Association (a
different colour scheme is used in Europe). Note that the limb electrodes can be far down on the limbs or close to
the hips/shoulders, but they must be even (left vs right).[15]

12 leads
Electrode label Electrode placement
 (in the USA)
RA On the right arm, avoiding bony prominences.
LA In the same location that RA was placed, but on the left arm this time.
RL On the right leg, avoiding bony prominences.
LL In the same location that RL was placed, but on the left leg this time.
V1 In the fourth intercostal space (between ribs 4 & 5) just to the right of the sternum (breastbone).
V2 In the fourth intercostal space (between ribs 4 & 5) just to the left of the sternum.
V3 Between leads V2 and V4.
In the fifth intercostal space (between ribs 5 & 6) in the mid-clavicular line (the imaginary line that
V4
extends down from the midpoint of the clavicle (collarbone)).
Horizontally even with V4, but in the anterior axillary line. (The anterior axillary line is the
V5 imaginary line that runs down from the point midway between the middle of the clavicle and the
lateral end of the clavicle; the lateral end of the collarbone is the end closer to the arm.)
Horizontally even with V4 and V5 in the midaxillary line. (The midaxillary line is the imaginary
V6
line that extends down from the middle of the patient's armpit.)

[edit] Additional electrodes

The classical 12-lead ECG can be extended in a number of ways in an attempt to improve its sensitivity in
detecting myocardial infarction involving territories not normally "seen" well. This includes an rV4 lead which
uses the equivalent landmarks to the V4 but on the right side of the chest wall and extending the chest leads onto
the back with a V7, V8 and V9.

[edit] Limb leads

In both the 5- and 12-lead configuration, leads I, II and III are called limb leads. The electrodes that form these
signals are located on the limbs—one on each arm and one on the left leg.[16][17][18] The limb leads form the points
of what is known as Einthoven's triangle.[19]

• Lead I is the voltage between the (positive) left arm (LA) electrode and right arm (RA) electrode:

I = LA − RA.
• Lead II is the voltage between the (positive) left leg (LL) electrode and the right arm (RA) electrode:

II = LL − RA.
• Lead III is the voltage between the (positive) left leg (LL) electrode and the left arm (LA) electrode:

III = LL − LA.
Simplified electrocardiograph sensors designed for teaching purposes at e.g. high school level are generally
limited to three arm electrodes serving similar purposes. [20]

[edit] Unipolar vs. bipolar leads

There are two types of leads: unipolar and bipolar. Bipolar leads have one positive and one negative pole.[21] 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; however, the negative pole is a composite pole (Wilson's central terminal) made up of signals from lots
of other electrodes.[22] In a 12-lead ECG, all leads besides the limb leads are unipolar (aVR, aVL, aVF, V1, V2, V3,
V4, V5, and V6).

Wilson's central terminal VW is produced by connecting the electrodes, RA; LA; and LL, together, via a simple
resistive network, to give an average potential across the body, which approximates the potential at infinity (i.e.
zero):

[edit] Augmented limb leads

Leads aVR, aVL, and aVF are augmented limb leads (after their inventor Dr. Emanuel Goldberger known
collectively as the Goldberger's leads). They are derived from the same three electrodes as leads I, II, and III.
However, they view the heart from different angles (or vectors) because the negative electrode for these leads is a
modification of Wilson's central terminal. This zeroes out the negative 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 central terminal paved the way for the development of the augmented limb leads aVR, 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 right arm. The negative
electrode is a combination of the left arm (black) electrode and the left leg (red) electrode, which
"augments" the signal strength of the positive electrode on the right arm:

• 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 positive electrode on the left arm:

• Lead augmented vector foot (aVF) has the positive (red) electrode on the left leg. The negative electrode
is a combination of the right arm (white) electrode and the left arm (black) electrode, which "augments"
the signal of the positive electrode on the left leg:

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 central terminal. Together with leads I, II, and III, augmented limb
leads aVR, aVL, and aVF form the basis of the hexaxial reference system, which is used to calculate 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:
[edit] Precordial leads

The electrodes for the precordial leads (V1, V2, V3, V4, V5 and V6) are placed directly 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 electrode, 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 average, potential over the body). The precordial
leads view the heart's electrical activity in the so-called horizontal plane. The heart's electrical axis in the
horizontal plane is referred to as the Z axis.

[edit] Waves and intervals

Schematic representation of normal ECG

Animation of a normal ECG wave.

Detail of the QRS complex, showing ventricular activation time (VAT) and amplitude.

A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave, a QRS complex, a T wave, and a U
wave which is normally visible in 50 to 75% of ECGs.[23] The baseline voltage of the electrocardiogram is known
as the isoelectric line. Typically the isoelectric line is measured as the portion of the tracing following the T wave
and preceding the next P wave.

Feature Description Duration

RR The interval between an R wave and the next R wave is the inverse of the heart rate.
0.6 to 1.2s
interval Normal resting heart rate is between 50 and 100 bpm
During normal atrial depolarization, the main electrical vector is directed from the SA
P wave node towards the AV node, and spreads from the right atrium to the left atrium. This 80ms
turns into the P wave on the ECG.
The PR interval is measured from the beginning of the P wave to the beginning of the
PR QRS complex. The PR interval reflects the time the electrical impulse takes to travel
120 to 200ms
interval from the sinus node through the AV node and entering the ventricles. The PR interval is
therefore a good estimate of AV node function.
The PR segment connects the P wave and the QRS complex. This coincides with the
electrical conduction from the AV node to the bundle of His to the bundle branches and
PR
then to the Purkinje Fibers. This electrical activity does not produce a contraction 50 to 120ms
segment
directly and is merely traveling down towards the ventricles and this shows up flat on
the ECG. The PR interval is more clinically relevant.
The QRS complex reflects the rapid depolarization of the right and left ventricles. They
QRS
have a large muscle mass compared to the atria and so the QRS complex usually has a 80 to 120ms
complex
much larger amplitude than the P-wave.
The point at which the QRS complex finishes and the ST segment begins. Used to
J-point N/A
measure the degree of ST elevation or depression present.
ST The ST segment connects the QRS complex and the T wave. The ST segment
80 to 120ms
segment represents the period when the ventricles are depolarized. It is isoelectric.
T wave The T wave represents the repolarization (or recovery) of the ventricles. The interval 160ms
 from the beginning of the QRS complex to the apex of the T wave is 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).
ST
The ST interval is measured from the J point to the end of the T wave. 320ms
interval
The QT interval is measured from the beginning of the QRS complex to the end of the
300 to
QT T wave. A prolonged QT interval is a risk factor for ventricular tachyarrhythmias and
430ms[citation
interval sudden death. It varies with heart rate and for clinical relevance requires a correction for needed]
this, giving the QTc.
The U wave is not always seen. It is typically low amplitude, and, by definition, follows
U wave
the T wave.
The J wave, elevated J-Point or Osborn Wave appears as a late delta wave following the
J wave QRS or as a small secondary R wave . It is considered pathognomic of hypothermia or
hypocalcemia.[24]

There were originally four deflections, but after the mathematical correction for artifacts introduced by early
amplifiers, five deflections were discovered. Einthoven chose the letters P, Q, R, S, and T to identify the tracing
which was superimposed over the uncorrected labeled A, B, C, and D.[25]

[edit] Vectors and views

Graphic showing the relationship between positive electrodes, depolarization wavefronts (or mean electrical
vectors), and complexes displayed on the ECG.

Interpretation of the ECG relies on the idea that different leads (by which we mean the ECG leads I,II,III, aVR,
aVL, aVF and the chest leads) "view" the heart from different angles. This has two benefits. Firstly, leads which
are showing problems (for example ST segment elevation) can be used to infer which region of the heart is
affected. Secondly, the overall direction of travel of the wave of depolarisation can also be inferred which can
reveal other problems. This is termed the cardiac 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 considered. One component will be in the direction of the lead
and this will be revealed in the behaviour of the QRS complex and one component will be at 90 degrees to this
(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 that the wave of depolarisation is spreading through the heart in a direction that has some
component (of the vector) in the same direction as the lead in question.

[edit] Axis
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 depolarization wavefront (or mean
electrical vector) in the frontal plane. With a healthy conducting system the cardiac axis is related to where the
major muscle bulk of the heart lies. Normally this is the left ventricle with 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 round to the left
beyond -30°, alternatively in conditions where the right ventricle is strained or hypertrophied then the axis swings
round beyond +90° and "right axis deviation" is said to exist. Disorders of the conduction system of the heart can
disturb the electrical axis without necessarily reflecting changes in muscle bulk.

−30° to
Normal Normal Normal
90°
Left axis deviation is considered normal
Left axis −30° to May indicate left anterior fascicular block or
in pregnant women and those with
deviation −90° Q waves from inferior MI.
emphysema.
May indicate left posterior fascicular block, Q Right deviation is considered normal in
Right axis +90° to
waves from high lateral MI, or a right children and is a standard effect of
deviation +180°
ventricular strain pattern. dextrocardia.
Extreme right +180° to Is rare, and considered an 'electrical no-man's
axis deviation −90° land'.

In the setting of right bundle branch block, right or left axis deviation may indicate bifascicular block.

[edit] Clinical lead groups

There are twelve leads in total, each recording the electrical activity of the heart from a different perspective,
which also correlate 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 contiguous
(see color coded chart). 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

Color on
Category Leads Activity
chart
Inferior Yellow Leads II, III Look at electrical activity from the vantage point of the inferior surface
leads and aVF (diaphragmatic surface of heart).
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
Lateral I, aVL, V5
Green the left arm and because of which, leads I and aVL are sometimes
leads and V6
referred to as the high 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 Look at electrical activity from the vantage point of the septal wall of the
Orange V1 and V2
leads ventricles (interventricular septum).
Anterior Look at electrical activity from the vantage point of the anterior surface of the
Blue V3 and V4
leads heart (sternocostal surface of heart).

In addition, any two precordial leads that are next to one another are considered to be contiguous. For example,
even though V4 is an anterior lead and V5 is a lateral lead, they are contiguous because they are next to one
another.

Lead aVR offers no specific view of the left ventricle. Rather, it views the inside of the endocardial wall to the
surface of the right atrium, from its perspective on the right shoulder.

[edit] Filter selection

Modern ECG monitors offer multiple filters for signal processing. The most common settings are monitor mode
and diagnostic mode. In monitor mode, the low frequency 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 filter (also called
the low-pass filter because signals below the threshold are allowed to pass) is set at 40 Hz. This limits artifact for
routine cardiac rhythm monitoring. The high-pass filter helps reduce wandering baseline and the low-pass filter
helps reduce 50 or 60 Hz power line noise (the power line network frequency 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. Consequently, the monitor mode ECG display is
more filtered than diagnostic mode, because its passband is narrower.[26]

[edit] Indications
Symptoms generally indicating use of electrocardiography include:

• Cardiac murmurs [27]

• Syncope or collapse[27]
• Seizures[27]
• Perceived dysrhythmias[27]
• Symptoms of myocardial infarction. See Electrocardiography in myocardial infarction

It is also used to assess patients with systemic disease as well as monitoring during anesthesia and critically ill
patients.[27]

[edit] Some pathological entities which can be seen on the ECG

Shortened QT interval Hypercalcemia, some drugs, certain genetic abnormalities.
Prolonged QT interval Hypocalcemia, some drugs, certain genetic abnormalities.
Flattened or inverted T waves Coronary ischemia, left ventricular hypertrophy, digoxin effect, some drugs.
Hyperacute T waves Possibly the first manifestation of acute myocardial infarction.
Prominent U waves Hypokalemia.