Electrocardiogram

ECG (Electrocardiogram)
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 Definition
 Anatomy of heart
 Structure of ECG
 Normal ECG
 Electrode positioning
 Clinical significance and applications
Definition
 Bioelectricity that produced by the electric excitation of the
heart can be detected through electrodes.
 A kind of continuous diagram recorded to reflect all electric

activities of heart.
Anatomy of heart
Diastole
Anatomy of heart
Systole
Heart Conduction System
HIS Bundle
Right bundle branch
Left bundle branch

Heart Conduction System
Structure of ECG
Normal Electrocardiogram
Normal ECG
 P wave : Atrial depolarization
Duration<0.12s
Amplitude<0.25mv
 P-R interval : Atrial and ventricular conducting time
Duration 0.12-0.20s
 QRS complex : Ventricular depolarization
Duration 0.06-0.10s
 ST- segment
descending < 0.05mv
elevating < 0.1mv
 T wave : ventricular repolarization
 Q-T interval : duration 0.32-0.44s
 U wave : ventricular subsequence potential
Three major waves of ECG
 P wave: It records the electrical activity of
the heart's two upper chambers (atria).
 QRS wave: records the electrical activity
of the heart's two lower chambers
(ventricles).
 T wave: It records the heart's return to the
resting state.
P Wave
 represents the sequential activation of the right and left atria,
 it is common to see notched or biphasic P waves of right and
left atrial activation.
 P duration < 0.12 sec

 P amplitude < 2.5 mm
 Frontal plane P wave axis: 0o to +75o
 May see notched P waves in frontal plane
QRS Complex
 The QRS represents the simultaneous activation of the
right and left ventricles, although most of the QRS
waveform is derived from the larger left ventricular
musculature.
 QRS duration < 0.10 sec

 QRS amplitude is quite variable from lead
to lead and from person to person
T wave
 It records the heart's return to the resting
state.
ST Segment and T wave
 continuous waveform beginning with the J-point

(end of QRS) to beginning of the T wave
Basic principle
 Electrodes are placed on the skin for certain distance to
collect the bioelectricity of heart.The alinement between
two electrodes constitute a lead which is directional.
 The bioelectricity is identified,calculated, amplified and

outputted through electronic system.
Bipolar limb leads (frontal plane):
Lead I: RA (-) to LA (+) (Right Left, or lateral)
Lead II: RA (-) to LF (+) (Superior Inferior)
Lead III: LA (-) to LF (+) (Superior Inferior)

Augmented unipolar limb leads (frontal plane):
Lead aVR: RA (+) to [LA & LF] (-) (Rightward)
Lead aVL: LA (+) to [RA & LF] (-) (Leftward)
Lead aVF: LF (+) to [RA & LA] (-) (Inferior)

Unipolar (+) chest leads (horizontal plane):
Leads V1, V2, V3: (Posterior Anterior)
Leads V4, V5, V6:(Right Left, or lateral)

Electrode positioning (3 lead)
• R/RA right arm  I
• L/LA left arm  II
• F/LL left leg  III
RA LA
LL
Electrode positioning (5 lead )
• R/RA right arm

• L/LA left arm
• F/LL left leg
• C/V chest
• N/RL right leg
Display waveforms of I, II, III

avR , avL, avF,V
Electrode positioning (12-lead )
 10 electrodes and leads attached to the patient (4 limb and 6 chest leads)
 Right leg lead electrode serves as a neutral electrode
 Records
 limb lead tracings (I, II, III, aVR, aVF, aVL),
 chest lead tracings (V1,V2 ,V3 ,V4 ,V5 ,V6)
V1 ： the 4th intercostal space on the right side of the sternum ；
V2 ： the 4th intercostal space on the left side of the sternum ；
V3 ： between the points V2 and V4 ；
V4 ： located in the fifth intercostal space at the midclavicular line ；
V5 ： at the same horizontal level as V4 but on the anterior axillary line ；
V6 ： at the same horizontal level as V4 but at the midline
the label used to identify each leadwire
American (AHA) European (IEC)

Standard Standard
Color Label Color
Label
RA White R Red
LA Black L Yellow
LL Red F Green
RL Green N Black
V Brown C White
Clinical significance and applications
 Indication for changes in the anatomy, metabolism,

hemodynamics, electrophysiology of the heart.
 Clew to estimate the type of cardiac arrhythmias.
 First filtration for potential cardiac disease patients.
 Important method to diagnose angina pectoris,

cardiomyopathy, Pericarditis.
 Representation for atrial enlargement and

ventricular hypertrophy.
 Helpful to know the impacts of certain

drugs,electrolytes and acid-base disturbance on
heart.
 ECG monitoring for critical patients.

 Coronary atherosclerotic heart disease
 Miocardial infarction
 Angina pectoris
 Ischemia
 Latent coronary heart disease
 Rheumatic heart disease P wave >0.12s
 Corpulmonale P wave; right ventricular
hypertrophy
 Hypertension: left ventricular hypertrophy
 Acid-base disturbance
 Electrolytes disturbance
 Drug concentration, eg:digitoxin
 Cardiac arrhythmias
What is arrhythmia?
 The number of times the heart beats each minute
(BPM) is called the heart rate.
Newborn: 140 BPM
Adolescent: 70-80 BPM
Adult: 60-70 BPM
 If the heart isn't beating regularly, it has an

arrhythmia.
Common kinds of Arrhythmia
 ASYSTOLE No QRS is detected for 4 consecutive seconds
 VFIB/VTAC Fibrilatory wave for consecutive 4 seconds.
 VT>2 3≦the number of cluster
 COUPLET 2 consecutive PVCs
 BIGEMINY Vent Bigeminy
 TRIGEMINY Vent Trigeminy
 R ON T a kind of PVC that the R on T
 PVC premature ventricular beat
 TACHY tachycardia
 BRADY bradycardia
 MISSED BEATS
 PNP pacer not paced
 PNC pace not capture
Sinus Tachycardia Atrial premature Beats
Premature ventricular Beats Ventricular fibrillation

Bigeminy
Trigeminy
Couple
Pacemaking ECG
 Artificial cardiac pacing is the method with
pacemaker to emit artificial pulse electricity to
stimulate heart and drive the heart beat.
 Pacemaking signal detected is marked by a

" ︱ " above the ECG waveform.
Pacemaker lead wire replacement
Atrial Pacing ECG
Coronary Artery
Atherosclerosis
Signification of ST segment deviation
Elevation
• Acute miocardial infarction
• Acute pericarditis
• Variant angina Pectoris

etc.
ST segment depression
Signification of ST segment deviation
Depression
• Coronary atherosclerotic
heart disease
• Myocardial ischemia
• Bundle Block
• Digitalis toxicity etc.
Adjusting ISO, ST
 ISO: It is the base point, used to indicate the baseline
point of the ST analysis. The default is 78ms.
 ST: It is the ST measurement point. The default is 109ms.
 ISO and ST, should be adjusted if the patient’s HR or
ECG morphology changes significantly.
ECG Parameters
ECG label Heartbeat icon
Heart rate value

Alarms Disabled icon
Why to use 12-Lead ECG?
 Anterior area
 V1, V2, V3, V4
 Lateral area
 I, aVL, V5,V6
 Inferior area
 II, III, aVF
I V1
 Typical (“normal”) 12-lead ECG tracing

II V2
 The standard procedure is to take the
III V3 “Rest 12-lead ECG” using a ECG cart
aVR  This is also called “diagnostic ECG”
V4
aVL
V5
aVF V6
 Screening the heart from different
views
 Sensitivity of recognizing ischemia
with 3-lead cable is not sufficient
 Sensitivity to track ischemic event
by 5 electrodes (V5 used) is up to
75% (London et al. 1988)
 Sensitivity to track ischemic event
by 10 electrodes (V1 -V6 used)
close to 100% (London et al. 1988)
Example: Acute anterior myocardial infarction
 To diagnose arrhythmias
- atrial or supraventricular premature beats
- premature ventricular contractions (PVC)
 To diagnose conduction failures

- Bundle Branch Blocks (LBBB, RBBB)
- AV blocks
Right Bundle Branch Block
A 55 year old man with 4 hours of "crushing" chest
pain.
EASI 12 lead （ PHILIPS ）
Questions?

Electrocardiogram

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ECG (Electrocardiogram)

To devote ourselves to and persist in providing

safe, high-performance and reliable medical

equipment and services with the most competitive

prices to the world for the well-being of mankind

and creating value for customers, shareholders,

 A kind of continuous diagram recorded to reflect all electric

Right bundle branch

Left bundle branch

 P duration < 0.12 sec

 QRS duration < 0.10 sec

 continuous waveform beginning with the J-point

 The bioelectricity is identified,calculated, amplified and

Lead I: RA (-) to LA (+) (Right Left, or lateral)

Lead II: RA (-) to LF (+) (Superior Inferior)

Lead III: LA (-) to LF (+) (Superior Inferior)

Lead aVL: LA (+) to [RA & LF] (-) (Leftward)

Lead aVF: LF (+) to [RA & LA] (-) (Inferior)

Leads V4, V5, V6:(Right Left, or lateral)

• R/RA right arm

Display waveforms of I, II, III

American (AHA) European (IEC)

 Indication for changes in the anatomy, metabolism,

 Clew to estimate the type of cardiac arrhythmias.

 First filtration for potential cardiac disease patients.

 Important method to diagnose angina pectoris,

 Representation for atrial enlargement and

 Helpful to know the impacts of certain

 ECG monitoring for critical patients.

 If the heart isn't beating regularly, it has an

Premature ventricular Beats Ventricular fibrillation

 Pacemaking signal detected is marked by a

• Variant angina Pectoris

ECG label Heartbeat icon

Heart rate value

 Typical (“normal”) 12-lead ECG tracing

 To diagnose conduction failures

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