THE DEVELOPMENT OF THE 12-LEAD ECG

Each ECG lead measures the electrical potential between two

electrodes, one negative and one positive. Current flowing
towards the positive electrode results in an upward deflection of
the ECG, and current flowing away from the positive electrode
results in a downward deflection.
Eindhoven originally described the detection of current between
electrodes placed on the right arm, left arm and left leg. This
resulted in three bipolar limb leads, I, II and III, which formed an
equilateral triangle around the heart (lead I: right arm negative,
left arm positive; lead II: right arm negative, left leg positive; lead
III: left arm negative, left leg positive). Unipolar leads were then
added which measured the potential between an exploring positive
electrode and a central terminal located at the centre of the heart,
which was formed by combining the right arm, left arm and left leg
leads. It was subsequently found that for the limb leads, the amplitude
of the recorded potential was augmented if the connection to
the limb for which the potential was being recorded was omitted
from the combined electrode, and these leads were termed augmented
limb leads (aVR, aVL and aVF). The addition of these
three augmented leads and six unipolar precordial leads (V\ to Vg)
gave rise to the modern 12-lead ECG.

MECHANISMS OF CARDIAC ARRHYTHMIAS

Arrhythmias may be caused by either abnormal impulse initiation
or abnormal impulse conduction. Either problem may lead to
brady- or tachyarrhythmias.

Abnormal impulse initiation

Many cells have the potential for automatic depolarization.
Normally, impulses generated in the sinus node and spreading
through the heart cause depolarization of these cells before they
depolarize spontaneously. Disease of the SA node or excessive

Abnormal impulse conduction

Block of conduction between the SA node and ventricular cells
may be partial or complete. Slowing of conduction near the AV
node or in the AV bundle results in prolongation of the PR interval
on the ECG (first degree heart block). If the block worsens,
this can progress to a situation where some atrial beats are not followed
by ventricular beats (second degree heart block). Finally a
situation may develop in which no atrial impulses pass to the ventricles,
which then beat at a slower independent rate (third degree
heart block). Block of conduction further down the conducting
system in either or both fascicles of the left bundle branch or the
right bundle branch alters the order of the spread of conduction
through the ventricles, producing characteristic ECG changes

(Fig. 5.9).
Re-entry arrhythmias occur when there is an area of the heart
in which there is a block to the spread of depolarization in one
direction but not the other (Fig. 5.10). Consequently, there may
develop a situation in which there is 'reverse' flow of depolarization
through that area with recirculation of the impulse. Such
phenomena may occur in all areas of the heart, leading to
supraventricular tachycardias, atrial fibrillation or flutter, ventricular
tachycardia or ventricular fibrillation. Patients with accessory
conduction pathways such as in Wolff-Parkinson-White syndrome