1. Electrocardiography-ECG/EKG
Is a transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes. It is a noninvasive recording produced by an electrocardiographic device

2. ECG graph paper Paper moves at a speed of 25mm/second At this speed
Each horizontal small cube represents 0.04 seconds
Each vertical small- 0.1 mv
Large cube- horizontal- 0.2 seconds
Large cube- vertically- 0.5 mv

4. Important features of the ECG are the P wave, the QRS complex and T wave.
Relevant intervals and segments are the PR interval, the RR interval, the QT segment and the ST segment.
ECG Paper
The ECG is recorded on calibrated paper. Refer to figure 1. The y-axis is voltage and 10 small
divisions represent 1 mV. (Note how much smaller these extracellular potentials are compared
with the amplitude of a single intracellular cardiac action potential (amplitude is ~ 120 mV). The
x-axis is time and a one division consisting of 5 smaller divisions represents 0.20 s. The actual
amplitude of the ECG signals depend on where the surface electrodes are actually placed.

6. P wave: Atrial depolarization as recorded from the surface of the
body
P – R interval: Time taken for the wave of depolarization to move through
the atria, AV node, bundle of His, Purkinje fibres to the
ventricular myocardium.
QRS complex: Depolarization of the ventricles.
ST segment: Marks the end of the QRS complex and the beginning of
the T wave. It occurs when the ventricular cells are in the
plateau phase of the action potential (i.e. there is no change
in potential occurring and so the ECG baseline is at zero
potential)
T wave: Repolarization of the ventricles (due to potential changes
occurring during phase 3 of the cardiac action potential)
Q – T interval: Period during which ventricular systole occurs
R – R interval: This time is usually used to calculate the heart rate.

7. Waves and normal values
P wave- Atrial depolarization
0.1 seconds
0.25 milli volts
PR interval- AV nodal delay
0.12 seconds seconds
QRS complex- ventricular depolarization
seconds

8. Normal Duration(s) Average Range Events on the heart during intervals
ECG intervals
Intervals
Normal Duration(s) Average Range
Events on the heart during intervals
PR interval1
Atrial depolarization and conduction through AV node
QRS duration
to 0.10
Ventricular depolarization and atrial repolarization
QT interval
to 0.43
Ventricular depolarization plus ventricular repolarization
ST interval (QT-QRS) …
Ventricular repolarization
1Measured from the beginning of the P wave to the beginning of the QRS complex 2Shortens as heart rate increases from average of 0.18 at a rate of 70 beats/min to 0.14 at a rate of 130 beats/min

9. EKG RULES:
A wave of depolarization traveling toward a positive electrode results in a positive deflection in the ECG trace.
2) A wave of depolarization traveling away from a positive electrode results in a negative deflection.
3) A wave of repolarization traveling toward a positive electrode results in a negative deflection.
4) A wave of repolarization traveling away from a positive electrode results in a positive deflection.

10. EKG RULES: continued
5)A wave of depolarization or repolarization traveling perpendicular to an electrode axis results in a biphasic deflection of equal positive and negative voltages (i.e., no net deflection).
6) The instantaneous amplitude of the measured potentials depends upon the orientation of the positive electrode relative to the Mean QRS vector.
7)The voltage amplitude is directly related to the mass of tissue undergoing depolarization or repolarization.

11. EKG Leads
Leads are electrodes which measure the difference in electrical potential between either:
1. Two different points on the body (bipolar leads)
2. One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart (unipolar leads)
Electrocardiographic Leads
The potentials generated by the heart can be picked up by 12 pairs of electrodes,
strategically located, with each pair “looking” at the heart from a slightly different angle.
By observing the recordings from the 12 leads, which can appear simultaneously on an
ECG machine, it is possible to detect many abnormalities in cardiac function.
Abnormalities of rhythm would be detected by all pairs of electrodes but abnormalities in
conduction, caused by an ischemic area of damage, might be picked up on some
recordings but not others.

12. EKG Leads The standard EKG has 12 leads: 3 Standard Bipolar Limb Leads
3 Augmented Unipolar Limb Leads
6 Precordial Leads
The axis of a particular lead represents the viewpoint from which it looks at the heart.

13. ECG recordings from Bipolar Limb Leads
In Lead I the negative terminal of the ECG machine is connected to the right arm and the
positive terminal to the left arm. This is simply just a convention so that
when depolarization spreads through the cardiac tissue an upward deflection will be
recorded from all three leads. Remember that upward deflections are recorded when the
wave of depolarization travels towards the positive electrode. Remember the direction of
the mean QRS vector.
Note that the largest amplitude positive deflection in each is the QRS complex. It is
bigger in Lead II simply because the axis of lead II is more in line with the direction of
ECG recordings from Bipolar Limb Leads

14. Einthoven’s Triangle Lead I at the top of the triangle, is
hypothetical triangle created around the heart when electrodes are placed on both arms and the left leg .The sides of the triangle are numbered to correspond with the three leads ("leeds"), or pairs of electrodes.
ECG electrodes at­tached to both arms and the left leg form a triangle. Each two-electrode pair constitutes one lead (pronounced "leed"), and only one lead is active at a time. Lead I, for instance, has the negative electrode attached to the right arm and the positive electrode at­tached to the left arm.
Lead I at the top of the triangle, is
orientated horizontally across the chest. This angle is taken as zero.
Lead II is angled at 60 degrees to Lead I, and Lead III at roughly 120 degrees to Lead I.

15. Augmented Unipolar Limb Leads (aVR, aVL and aVF)
Three unipolar limb leads are also used for recording ECGs. Each lead measures the potential difference between an exploring electrode and an “indifferent” electrode (V) assumed to be at zero potential. This indifferent electrode is constructed by connecting the electrodes on the right arm (R), left arm (L) and left leg or foot (F) together. This indifferent electrode is called V and is assumed to be at zero potential (since the sum of the potentials in all the leads cancel out).

16. Augmented limb leads Represented by aVR, aVF, aVR. a- augmented
V-unipolar
Last letter represents the part of body
aVR- between right arm and left arm+ left leg
aVL- between left arm and rt arm+ left leg
aVF- between left foot and rt arm+ lt arm

17. ECG recordings from Bipolar Limb Leads
Right arm
Left arm
In Lead I the negative terminal of the ECG machine is connected to the right arm and the
positive terminal to the left arm. This is simply just a convention so that
when depolarization spreads through the cardiac tissue an upward deflection will be
recorded from all three leads. Remember that upward deflections are recorded when the
wave of depolarization travels towards the positive electrode. Remember the direction of
the mean QRS vector.
Note that the largest amplitude positive deflection in each is the QRS complex. It is
bigger in Lead II simply because the axis of lead II is more in line with the direction of
III II
Left leg
ECG recordings from Bipolar Limb Leads

18. Einthoven’s Triangle ECG recordings from Bipolar Limb Leads -900 I
aVR
aVL
-300
-1500 I
+1800
Right arm 00
Left arm
III II
600
1200
In Lead I the negative terminal of the ECG machine is connected to the right arm and the
positive terminal to the left arm. This is simply just a convention so that
when depolarization spreads through the cardiac tissue an upward deflection will be
recorded from all three leads. Remember that upward deflections are recorded when the
wave of depolarization travels towards the positive electrode. Remember the direction of
the mean QRS vector.
Note that the largest amplitude positive deflection in each is the QRS complex. It is
bigger in Lead II simply because the axis of lead II is more in line with the direction of
+900
+aVF
Left leg
ECG recordings from Bipolar Limb Leads

19. Precordial Leads
These are unipolar leads measuring the potential difference between an electrode placed on the chest and an indifferent electrode, again made up by connecting the RA, LA and LL electrodes (i.e. the V electrode). There are 6 locations to place the chest electrode and
so there are 6 chest electrodes (V1 – V6).
With the chest leads, if the chest electrode is in an area of positivity, which occurs if the wave of depolarization is approaching this electrode, then an upward deflection is recorded.
Adapted from:

20. Precordial Leads

21. Pre cordial leads V1- 4th intercoastal space, rt side sternal boarder
V2- 4th intercoastal space lt side of sternal boarder
V3- between V2 and V4
V4- 5th intercoastal space in the mid clavicular space
V5- 5th intercoastal space in the anterior axillary line
V6- 5th intercoastal space in the mid axillary line.

22. aVR, aVL, aVF (augmented limb leads)
Summary of Leads
Limb Leads
Precordial Leads
Bipolar
I, II, III
(standard limb leads) -
Unipolar
aVR, aVL, aVF (augmented limb leads)
V1-V6

23. Leads I, II and III have a QRS complex that is positive (upward deflection) because in all
three, the direction of electrical conduction is primarily towards the positive electrode.
The magnitude of the QRS complex will be largest in lead II because the mean QRS
vector of the heart is closer to the axis of Lead II than it is to Lead I or III. (Remember
figure 3).
In the augmented limb leads aVL and aVF the QRS complex is positive, again because
the positive electrode (left arm, left foot) is more aligned with the mean QRS vector. On
the other hand, aVR will have a negative QRS complex because the wave of
depolarization is moving away from the right arm (positive electrode).
In the precordial chest leads, V1 through to V4 QRS changes from negative to positive as
the positive electrode for each subsequent lead is more in line with the mean QRS vector
than the previous one. Leads V5 and V6 are most in line with the mean QRS vector so
their QRS complexes are positive

24. Anatomic Groups (Summary)
Lateral
aVR
None V1
Septal V4
Anterior II
Inferior
aVL
Lateral V2
Septal V5
Lateral
III
Inferior
aVF
Inferior V3
Anterior V6
Lateral

25. INTERPRETATION OF THE ELECTROCARDIOGRAM
What to inspect in an ECG
Heart Rate
Rhythm
Duration, Segments and intervals. (P wave duration, PR interval, QRS duration, QT interval)
Mean QRS Axis (mean electrical axis, mean QRS vector)
P wave abnormalities
Inspect the P waves in leads II and V1 for left atrial and right atrial enlargement.
Left atrial hypertrophy would result in a taller P wave in Lead II
RA hypertrophy – taller P wave in V1
QRS wave abnormalities
ST segment/T wave abnormalities

26. 1 Heart Rate Rule of 300 (300 / 6) = 50 bpm (1500/30) = 50 bpm
Take the number of “big boxes” between neighboring QRS complexes( R – R interval), and divide this by The result will be approximately equal to the rate
Although fast, this method only works for regular rhythms.
(300 / 6) = 50 bpm
(1500/30) = 50 bpm

27. What is the heart rate? (300 / ~ 4) = ~ 75 bpm (1500/20 ) = 75 bpm
(300 / ~ 4) = ~ 75 bpm
(1500/20 ) = 75 bpm

28. What is the heart rate? (300 / 1.5) = 200 bpm
Heart Rate < 60 beats / min  Bradycardia
Heart Rate > 100 beats / min Tachycardia

29. The Rule of 300 It may be easiest to memorize the following table:
# of big boxes
Rate 1
300 2
150 3
100 4 75 5 60 6 50

30. Rhythm
Is the rhythm determined by the SA node pacemaker? i.e. is it a “sinus rhythm”?
If normal, the following should be present:
· The P wave should be upright in leads I, II and III.
· Each QRS complex should follow a P wave

31. P wave
The P wave represents atrial depolarization. In normal EKGs, the P-wave preceeds the QRS complex. It looks like a small bump upwards from the baseline. The amplitude is normally 0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is seconds (1.5 to 2.75 small boxes). The shape of a P-wave is usually smooth and rounded.  P-wave questions: Are they present?
Do they occur regularly?
Is there one P-wave for each QRS complex?
Are the P-Waves smooth, rounded, and upright?
Do all P-Waves have similar shapes?
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32. P wave- Atrial depolarization
Duration, Segments and intervals. (P wave duration, PR interval, QRS duration, QT interval)
P wave- Atrial depolarization
0.1 seconds (21/2 small boxes)
0.25 milli volts
PR interval- AV nodal delay
0.12 seconds- 0.2 seconds (5 small boxes)
QRS complex- ventricular depolarization
seconds
QT Interval 0.4 seconds (10 small boxes)

33. Einthoven’s Triangle Lead I at the top of the triangle, is
hypothetical triangle created around the heart when electrodes are placed on both arms and the left leg .The sides of the triangle are numbered to correspond with the three leads ("leeds"), or pairs of electrodes.
ECG electrodes at­tached to both arms and the left leg form a triangle. Each two-electrode pair constitutes one lead (pronounced "leed"), and only one lead is active at a time. Lead I, for instance, has the negative electrode attached to the right arm and the positive electrode at­tached to the left arm.
Lead I at the top of the triangle, is
orientated horizontally across the chest. This angle is taken as zero.
Lead II is angled at 60 degrees to Lead I, and Lead III at roughly 120 degrees to Lead I.

34. All Limb Leads

35. The QRS Axis
The QRS axis represents the net overall direction of the heart’s electrical activity.
Abnormalities of axis can hint at:
Ventricular enlargement
Conduction blocks (i.e. hemiblocks)

36. The QRS Axis
By near-consensus, the normal QRS axis is defined as ranging from -30° to +90°.
-30° to -90° is referred to as a left axis deviation (LAD)
+90° to +180° is referred to as a right axis deviation (RAD)

37. Determining the Axis
The Quadrant Approach
The Geometric method.

38. Determining the Axis Predominantly Positive Predominantly Negative
Equiphasic

39. The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.

40. The Quadrant Approach
2. In the event that LAD is present, examine lead II to determine if this deviation is pathologic. If the QRS in II is predominantly positive, the LAD is non-pathologic (in other words, the axis is normal). If it is predominantly negative, it is pathologic.

41. Quadrant Approach: Example 1
The Alan E. Lindsay ECG Learning Center
Negative in I, positive in aVF  RAD

42. Quadrant Approach: Example 2
The Alan E. Lindsay ECG Learning Center
Positive in I, negative in aVF  Predominantly positive in II 
Normal Axis (non-pathologic LAD)

43. QRS Axis Determination- Using the Hexaxial Diagram
 First find the isoelectric lead if there is one; i.e., the lead with equal forces in the positive and negative direction. Often this is the lead with the smallest QRS.  The QRS axis is perpendicular to that lead's orientation.  Since there are two perpendiculars to each isoelectric lead, chose the perpendicular that best fits the direction of the other ECG leads.

45. Applied physiology Myocardial infarction- Q wave Ischemia-
elevated ST segment
Ischemia-
ST depression

46. Heart block- First Degree AV Block
There is a slowing of conduction through the AV node. The P-R interval is unusually
long (> 0.20 s). However each P wave is followed by a QRS complex.

47. Second Degree Block
As the PR interval increases to > 0.25s, sometimes conduction through the AV node fails and a P wave does not result in a QRS complex. This is intermittent conduction failure with a subsequent loss of ventricular contraction and is typical of a second degree block. There are 3 types of Second Degree Block:
Mobitz type I
Mobitz type II
Bundle Branch Block
Mobitz Type I
The PR interval gradually lengthens from one cycle to the next until the AV node fails
completely and no QRS complex is seen. One usually seen every third or fourth atrial
beat failing to excite the ventricle (3 : 1 block or 4 : 1 block). The PR interval then
immediately resets to the original interval and the process begins again. Mobitz type 1 is
usually due to a conduction block in the AV node and is generally benign. It may be seen
in children, athletes or individuals with elevated vagal tone. No specific treatment is
needed for this condition.
Mobitz Type II
In this condition there is a sudden, unpredictable loss of AV conduction and loss of
ventricular activation and is usually due to a conduction block beyond the AV node (e.g.
bundle of His). The PR interval remains constant from beat to beat but every nth
ventricular depolarization is missing. In Figure 15 the first cardiac cycle is normal,
however the second P wave is not followed by a QRS or T. Instead, the ECG record is
flat until the third P wave arrives at the expected time, followed by a QRS and a T wave.
Figure 6 Second Degree Conduction Block
In other words every second QRS is dropped (2 : 1 block). Mobitz type II is more
dangerous than type I as it could lead to cardiac arrest. Treatment is generally to implant
a pacemaker.
Bundle Branch Block
When the HR exceeds a critical level, the ventricular conduction system fails – probably
because the conduction system does not have adequate time to repolarize. As a result the
impulse spreads slowly and inefficiently through the ventricles by going from one
myocyte to the next (since the conducting system is now no longer working properly
which is why it is called bundle branch block). As a result the QRS complex is widened.
Because this block impairs the coordinated spread of the action potentials through the
myocardium the resulting ventricular contractions may be weaker.

48. Complete Conduction Block:- Third Degree Block
In this condition no impulse goes through the AV node. The atria and the ventricles are now severed – electrically speaking – and each beats under control of its own pacemakers. This is also called AV dissociation. The atria have an inherent rhythm of 60
– 80 bpm and the P-P interval will be regular and consisten. The only ventricular pacemaker that are available to initiate ventricular contractions are the Purkinje fibres - their inherent rhythm is 20 – 40 bpm.
The R – R interval may be regular and consistent.
The P – P interval will be faster than the R – R interval and there is no relation between
the two. If the ventricular excitation starts within cells of the conducting system (like the
Purkinje cells) then the QRS complex appears normal, but if excitation starts somewhere
else in the ventricular myocardium the QRS complex will be abnormal. Third degree
block is a medical emergency since the CO, and hence the BP can be seriously
compromised. Treatment is to implant a pacemaker.
On an ECG, the complete block appears as regularly spaced P waves (since the SA node
properly triggers the atria), but the QRS and T waves may be irregular, with a low
frequency and bearing no fixed relationship to the P waves

49. Hypokalemia: Flattened T wave ST depression More prominent U wave
Arrhythmias caused by changes in Electrolyte Composition
Both Hypokalemia and Hyperkalemia can cause serious cardiac arrhythmias. This is not surprising considering how dependent the membrane potential is on extracellular K+ levels. To treat arrhythmias due to hyperkalemia calcium gluconate is infused. Ca++ has the opposite effects to K+ on the action potential.
Hypokalemia:
Flattened T wave
ST depression
More prominent U wave
Hyperkalemia:
Peaked T wave
Loss of P wave
Widened QRS

50. Leads I, II and III have a QRS complex that is positive (upward deflection) because in all
three, the direction of electrical conduction is primarily towards the positive electrode.
The magnitude of the QRS complex will be largest in lead II because the mean QRS
vector of the heart is closer to the axis of Lead II than it is to Lead I or III. (Remember
figure 3).
In the augmented limb leads aVL and aVF the QRS complex is positive, again because
the positive electrode (left arm, left foot) is more aligned with the mean QRS vector. On
the other hand, aVR will have a negative QRS complex because the wave of
depolarization is moving away from the right arm (positive electrode).
In the precordial chest leads, V1 through to V4 QRS changes from negative to positive as
the positive electrode for each subsequent lead is more in line with the mean QRS vector
than the previous one. Leads V5 and V6 are most in line with the mean QRS vector so
their QRS complexes are positive

51. ECG 1
18-year-old pre-op ECG for knee surgery. What does this ECG show?
Limb lead reversal
Ectopic atrial rhythm (EAR)
Dextrocardia
Coronary sinus rhythm
Multifocal atrial rhythm (MAT)
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52. ECG 2
The above ECG, from an elderly woman, is least consistent with which of the following?  
Severe mitral stenosis
Severe aortic stenosis
Embolic stroke
Hypertensive heart disease
Severe aortic regurgitation
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53. ECG 3
This ECG from a 53 year old woman is most consistent with which of the following diagnoses?
a) Right ventricular hypertrophy
b) Posterior myocardial infarction and left posterior fascicular block
c) Wolff-Parkinson-White (WPW) preexcitation pattern
d) Simultaneous limb (left/right arm) and precordial lead reversal: normal ECG
e) Dextrocardia with situs inversus

54. ECG 4 This ECG from a young adult woman shows which of the following?
Wolff-Parkinson-White pattern with posterior septal pre-excitation
Dextrocardia with an otherwise normal heart
Normal variant persistent juvenile T-wave inversions
Posterior myocardial infarction with left posterior hemiblock
Severe right ventricular hypertrophy
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55. ECG 5 This ECG shows evidence of which of the following?
Wolff-Parkinson-White pre-excitation
Acute inferior myocardial infraction with intraventricular conduction delay
Complete left bundle branch block
Left bundle branch block and acute anterolateral myocardial infarction
Right bundle branch block with left anterior fascicular block
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56. ECG 6 What is the rhythm? Sinus Tachicardia Torsado de Pointe
Atrial Flutter
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57. ECG 7 Tall R waves What is abnormal in V1-V2 of this 48-year-old man?
a) Normal
b) Hypertrophic cardiomyopathy
c) Right ventricular hypertrophy
d) Posterior myocardial infarction
e) Duchenne muscular dystrophy
These tall R waves in V1 – V2 were due to....

58. Posterior wall “leads”

59. The Leads (with the posterior leads)
S (Septal)
A (Anterior)
L (lateral)
I (Inferior)
P (Posterior)
V1 and V2
V3 and V4
V5, V6, Lead I and aVL
Lead II, Lead III and aVF
V7, V8 and V9
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60. ECG 8
This ECG from a 77-year old woman is most consistent with which ONE of the following diagnoses?
a) Acute pericarditis
b) Acute inferior wall ST elevation infarction (STEMI)
c) Acute pulmonary embolism
d) Benign early repolarization variant
e) Brugada-pattern variant
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61. ECG 9
Which ONE of the following abnormalities is most likely present based on these waveforms?
a) Hypoaldosteronism
b) Hypokalemia
c) Hypocalcemia
d) Hyponatremia
e) Hypophosphatemiaion
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62. ECG 10
What diagnostic study is most appropriate in this 60-year-old man with rest chest pain?
Exercise stress test
Transthoracic echocardiogram
Cardiac catheterization/coronary angiography
Resting nuclear imaging test (e.g., sestamibi scan during pain)
Electron beam cardiac CT
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63. ECG 11
Which ONE of the following abnormalities is NOT present in the following ECG?
Premature atrial complexes (PACs)
Inferior Q-wave myocardial infarction
Left atrial abnormality
Infero-lateral ST-T abnormalities
AV Wenckebach
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64. ECG 12 This ECG is most consistent with which diagnosis?
Acute anterior myocardial infarction
Accelerated idioventricular rhythm
Marked hyperkalemia
Marked hypercalcemia
Systemic hypothermia
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65. ECG 13
This ECG (with some baseline artifact) from an elderly man shows which of the following?
Sinus tachycardia with Mobitz type I second degree AV block
Sinus tachycardia with Mobitz type II second degree AV block
Sinus tachycardia with blocked premature atrial complexes
Sinus rhythm with sinus exit block
Ectopic atrial rhythm with AV Wenckebach
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66. ECG 14
What AV conduction abnormality is present in this ECG showing sinus rhythm with right bundle branch block and left atrial abnormality?
Complete heart block
Isorhythmic AV dissociation
Mobitz Type I AV block (AV Wenckebach)
Mobitz Type II AV block
Sinus rhythm with blocked premature atrial beats
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67. ECG 15
80 year-old man presented to emergency department complaining of fatigue and shortness of breath? What is the rhythm?
a) Sinus tachycardia
b) Atrial tachycardia
c) AV nodal reentrant tachycardia (AVNRT)
d) Atrial flutter with 2:1 conduction
e) Atrial fibrillation
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68. ECG 16
Very elderly woman brought to the emergency department by her family for evaluation of a recent fall with complaints of fatigue and weakness. She was noted to have a very slow pulse. What is the rhythm?
Sinus rhythm with Mobitz II AV block
Sinus rhythm with isorhythmic AV dissociation
Sinus rhythm with third degree (complete) AV block
Sinus bradycardia with right bundle branch block (RBBB) and blocked atrial premature beats in a bigeminal pattern
Atrial tachycardia with complete heart block
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