BASIS OF ECG

1. Describe the “pacemaker potential” of the SA node and list the different pacemaker cells of the heart and the frequency
of action potentials for each.

REMINDER OF ACTION POTENTIALS OF THE HEART:

The pacemaker potential (phase 4) is not a true resting membrane potential. There is a progressive depolarization of
slow response action potential (fastest in the SA node).

Intrinsic pacemakers of the heart are: SA node (60-100bpm), AV node (40-60bpm)

2. List the normal sequence of cardiac activation beginning in the SA node and describe the role played by specialized
cells.

3. Explain why the AV node is the only normal electrical pathway between the atria and the ventricles and explain the
functional significance of the slow conduction through the AV node, as it relates to the ECG.

A collagen ring (insulator) between the atria and the ventricles separates their electrical activity. The fiber of His travels
from the AV node and enables ventricular contraction.

Low conduction through the AV node allows the ventricles to fill with blood before they contract.

4. Diagram the electrode placements and polarities for the 12 leads of a 12-lead ECG.

The electrocardiogram (ECG) measures the electrical activity of the heart recorded on the surface of the body.

There are 10 leads altogether: 4 limb leads, 6 chest leads (precordial leads). These produce 12 recordings – all 12 leads
are recording the SAME heartbeat simultaneously!

The standard limb leads (I, II, and III) record electrical activity in a frontal plane through the heart.

- Lead I is between the two arms, with the left arm being +.

- Lead II is between the right arm and the left leg, with the left leg being +.

- Lead III is between the left arm and the left leg, with the left leg being +.

Augmented limb leads (aVR, aVL, and aVF) are derived from the same three electrodes as the standard limb leads, but
view the heart from different angles (vectors); basically, take two limb leads and make them – and a third limb lead +.

The augmented leads are unipolar: aVR has + electrode on the right arm, aVL has + electrode on the left arm, and aVF has
+ electrode on the left leg.

The 6 precordial leads are also unipolar and always +. They record electrical activity in a transverse plane through the
heart (placed along an arc on the chest beginning just to the right of the sternum and proceeding under the left arm).
V1 looks primarily at the right heart, and so on.

5. State the parts of a typical bipolar lead (Lead II) ECG trace and explain the relationship between each of the waves,
intervals, and segments as well as the electrical state of the heart.

* A segment on the ECG trace is by definition a region of isoelectric neutrality; an interval is a region where at least one
wave is present.

* The P wave is the first positive deflection and represents the depolarization of the atrium (started by depolarization in
the SA node, which cannot be picked up by the ECG electrodes). The duration of the P wave reflects the time required
for the atrium to depolarize.

* The PR segment represents the time required for conduction of the action potential through the AV node, bundle of His,
and Purkinje system to the ventricular muscle.

* PR interval = P-wave + P-segment  shortens when heart rate increases (normally 0.12 – 0.20 sec; if > 0.20 sec AV
conduction block may be present).

* The QRS interval is the time required for ventricular depolarization (which initiates systole). Normal duration less
than 0.10 sec.

- Atrial repolarization is occurring at the same time but is obscured by the electrical activity of the ventricles.
* The ST segment reflects the complete depolarization of the ventricles. Elevated or depressed ST segments usually
indicate ischemic events in the ventricle.

* The T wave is the final deflection and represents ventricular repolarization. The T wave is a POSITIVE deflection
because: repolarization occurs in the opposite direction of depolarization (epicardium to endocardium) AND the direction
of ion movement is opposite to that of depolarization (- to +).

* The QT interval is the time required for the entire ventricle to undergo one cycle of depolarization/repolarization
(ventricular systole); proportional to heart rate. * normal QT should be < 1/2 R-R interval.

* The TP segment = diastole (both atria and ventricles are relaxed).

* The RR interval measures the duration of one complete cardiac cycle and can be used to determine heart rate.

6. Define the term dipole and describe how dipoles generated across the surface of the heart produce the waveforms of the
ECG trace.

At rest, the outer surface of heart cells is positive relative to the inside; when an action potential passes, the outer surface
becomes negative. The ECG records the surface charge, conducted to the skin via body fluids.

Action potential begins at SA node (produces negative surface), while the rest of the heart surface is positive  dipole.

As repolarization occurs, the heart at the SA node end become positive again, while the other end is still negative 
dipole reversed.

* When a wave of depolarization moves toward a POSITIVE electrode, an upward deflection is recorded on the ECG
trace and vice versa. (e.g. Lead II – left leg +, right arm -; depolarization goes toward left leg  upward deflections).

EXAMPLE: ECG trace for lead II

(a) P wave. Net depolarization from SA node to atria (right arm to left foot) moves in + direction (upward deflection).

(b) Q wave. Depolarization moves left to right across the septum muscle (slight downward deflection).

(c) R wave. Depolarization moves directly toward apex / + lead (large upward deflection).
 (d) S wave. Depolarization spreads up the walls of the ventricles, away from apex (downward deflection).

(e) T wave. Ventricle repolarization has reversal in polarity AND direction, so the deflection is upward.

7. Determine the following parameters from a typical bipolar ECG trace: heart rate, duration of atrial depolarization, AV
conduction time, and duration of ventricular depolarization.

ECG paper is standardized, with voltage in the y-axis and time in the x-axis.
~ Heart rate is calculated by counting the boxes between two R waves. (Each box is 0.04 sec, so for 20 boxes in the
R-R interval, you get 0.04 x 20 = 0.8 sec per heartbeat. 60 sec/min / 0.8 sec/beat = 75 bpm.

Any easy way to estimate heart rate:

* Intervals are calculated in the same way as the R-R interval from the ECG trace. Reminder: The PR interval should be
0.12-0.20 sec, QRS interval should be less than 0.10 sec, and QT interval should be less than ½ the R-R interval.

8. Describe the timing of the ECG events as related to the cardiac cycle.

The ECG shows the electrical events in the heart that precede the mechanical events described by the cardiac cycle.

INTRODUCTION TO ECG INTERPRETATION

1. Identify the ECG traces produced by each of the following: sinus tachycardia, sinus bradycardia, AV blocks (1 st, 2nd,
and 3rd), atrial fibrillation, and ventricular fibrillation.

The NORMAL heart rate is 60-100 bpm, with the PR interval 0.12-0.20 sec, the QRS complex less than 0.10 sec and the
QT interval less than ½ (R-R interval).

Abnormalities in the ECG trace can arise in:

- P wave, usually indicating atrial hypertrophy.

- QRS wave, usually indicating conduction block and/or ventricular hypertrophy.

- ST segment / T wave, usually indicating angina, MI, pericarditis, aneurysm, etc.

* Always compare ECG to previous (baseline) ECG trace from the same patient!

* Rhythm – Is the SA node working properly? Is P wave upright in lead I-III? Is there a QRS wave after every P wave?

A normal sinus rhythm indicates that the SA node is acting as the pacemaker of the heart.

Tachycardia occurs when the ECG is normal in all ways EXCEPT the heart rate is elevated (>100 bpm). Bradycardia
occurs when the heart rate is depressed (<60 bpm).
Atrioventricular (AV) conduction blocks prevent/delay impulses from the SA node to the ventricles (can occur at AV
node or lower). AV blocks can result from ischemic tissue damage, physical damage, inflammation, or extreme vagal
nerve activity.

- First degree (incomplete) block occurs when conduction to the ventricles is partially blocked. All PR intervals
exceed 0.20 sec AND a QRS complex follows every P wave. Electrical impulses can travel along alternate conduction
pathways, but it takes longer to do so.

- Second degree block is characterized by PR intervals > 0.25 and (sometimes) failure of the AV node and lack of
P wave.

~ Mobitz Type I second degree block shows progressive lengthening of the PT interval. Eventually,
atrial impulse fails to conduct through AV node, a QRS complex is not generated, and there is no ventricular
contraction. (Generally benign, seen in children and athletes, no specific treatment generally needed).

~ Mobitz Type II second degree block results in an unexpected loss of atrial impulse to the ventricles
with no prior measurable lengthening of the PR interval. 3:1 heart block (3 conducted, 1 blocked), usually due to
a conduction block beyond the AV node. (Can lead to cardiac arrest, treated with a pacemaker).

- Third degree block results in complete failure of conduction from the atria to the ventricles. The atria and
ventricles acquire two separate rhythms  the atria beat at their intrinsic rate of 60-100 bpm, the ventricles beat at 20 -40
bpm (P wave frequency > QRS). May sometimes be treated with drugs / pacemaker.

2. Describe a dangerous side effect of atrial fibrillation.

Fibrillation describes non-rhythmic cycles of contraction and relaxation caused when an action potential is slowed down
in a tissue and later excites a tissue that has already begun to repolarize (“re-entry current”).
* Atrial fibrillation is not directly fatal, but ventricular fibrillation is.

- The ECG trace during atrial fibrillation shows an absence of clear P waves and no coordination between the atria and
ventricles.

~ Dangerous side effects: blood pooling can form a thrombus, which can break apart and plug arterioles
(pulmonary, coronary, cerebral embolism).

- The ECG during ventricular fibrillation shows a total absence of any pattern.

3. Describe ECG changes associated with myocardial ischemia, injury, and death, and describe how the injury current
from these conditions alters the ST segment of the ECG.

Heart Rhythm

~ Regular rhythm: the R-R intervals are the same for each heartbeat. E.g. tachycardia, bradycardia, first degree block.

~ Regularly irregular rhythm: a pattern of repeating irregular beats. E.g. second, third degree block.

~ Irregularly irregular rhythm: has no underlying regularity at all. E.g. atrial fibrillation.

* Shifts in the S-T segment (elevation of depression) is a good indicator that a myocardial infarction (MI) or ischemic
event has occurred  myocardial cell damage, “current of injury” = damaged cells cannot maintain a resting potential.

4. Define mean electrical axis of the heart and give the normal range.

The mean electrical axis (MEA) shows the net direction of electrical conduction during ventricular depolarization
(indicates orientation of the heart, size of ventricular chambers, and conduction blocks).

Einthoven’s Triangle is formed by the three standard limb leads around the heart (shift the leads to intersect at one
points). The radial axis is used to determine the MEA of the heart.
Because the apex of the heart is located around Lead II, a normal patient’s MEA would be about 60 degrees.

5. Correlate changes in the mean electrical axis with changes in ventricular size.

6. Determine the direction of the mean electrical axis using the net direction of the QRS complexes in the 6 leads.

I. The semi-quantitative method of determining MEA uses the net direction of QRS complexes of all six limb leads.

II. The net zero lead method can only be used if a lead has a net zero QRS complex (+ deflection of a lead is
approximately equal to the negative deflection).
7. Estimate the direction of the mean electrical axis using the net direction of the QRS complexes in Lead I and aVF in
order to determine right or left axis deviation.

III. The “quick and dirty” method derives the MEA from the net direction of QRS complexes in Lead I and aVF (shows
right / left axis deviation).

RESULTS:

~ A normal MEA is found between 0 and +90 degrees.

~ A left axis deviation is from 0 to -90 degrees. Possible causes: left ventricular hypertrophy, inferior MI, emphysema.

~ A right axis deviation is from +90 to +150 degrees. Possible causes: normal finding in children and tall, thin adults,
right ventricular hypertrophy, chronic lung disease with pulmonary hypertension, pulmonary embolus.

SEE SLIDES 26-30 FOR PRACTICE Q’S.