ACKNOWLEDGEMENT

I would like to express my special thanks of gratitude to my

teacher NISHIKANTA DAS as well as our principal SWAPNA
SHOME who gave me the golden opportunity to do this
wonderful project on the topic ECG, which also helped me in
doing a lot of Research and I came to know about so many new
things I am really thankful to them.

Secondly I would also like to thank my parents and friends who

helped me a lot in finalizing this project within the limited time
frame.

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INTRODUCTION

Electrocardiography (ECG or EKG) is the process of recording the

electrical activity of the heart over a period of time using electrodes
placed over the skin. These electrodes detect the tiny electrical changes
on the skin that arise from the heart muscle's electro physiologic pattern
of depolarizing and repolarizing during each heartbeat. It is very
commonly performed to detect any cardiac problems.
In a conventional 12-lead ECG, ten electrodes are placed on the patient's
limbs and on the surface of the chest. The overall magnitude of the heart's
electrical potential is then measured from twelve different angles
("leads") and is recorded over a period of time (usually ten seconds). In
this way, the overall magnitude and direction of the heart's electrical
depolarization is captured at each moment throughout the cardiac cycle.
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The graph of voltage versus time produced by this non-invasive medical
procedure is an electrocardiogram.
There are three main components to an ECG: the P wave, which
represents the depolarization of the atria; the QRS complex, which
represents the depolarization of the ventricles; and the T wave, which
represents the repolarization of the ventricles. It can also be further
broken down into the following:

 O is the origin or datum point preceding the cycle.

 P is the atrial systole contraction pulse.
 Q is a downward deflection immediately preceding the ventricular
contraction.
 R is the peak of the ventricular contraction.
 S is the downward deflection immediately after the ventricular
contraction.
 T is the recovery of the ventricles.
 U is the successor of the T wave but it is small and not always.

HISTORY OF ECG

The etymology of the word is derived from the Greek electro, because it
is related to electrical activity, kardio, Greek for heart, and graph, a Greek
root meaning "to write".
Alexander Muirhead is reported to have attached wires to a feverish
patient's wrist to obtain a record of the patient's heartbeat in 1872 at St
Bartholomew's Hospital. Another early pioneer was Augustus Waller, of
St Mary's Hospital in London. His electrocardiograph machine consisted
of a Lippmann capillary electrometer fixed to a projector. The trace from
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the heartbeat was projected onto a photographic plate that was itself fixed
to a toy train. This allowed a heartbeat to be recorded in real time.
An initial breakthrough came when Willem Einthoven, working in
Leiden, the Netherlands, used the string galvanometer (the first practical
electrocardiograph) he invented in 1901. This device was much more
sensitive than both the capillary electrometer Waller used and the string
galvanometer that had been invented separately in 1897 by the French
engineer Clément Ader. Einthoven had previously, in 1895, assigned the
letters P, Q, R, S, and T to the deflections in the theoretical waveform he
created using equations which corrected the actual waveform obtained by
the capillary electrometer to compensate for the imprecision of that
instrument. Using letters different from A, B, C, and D (the letters used
for the capillary electrometer's waveform) facilitated comparison when
the uncorrected and corrected lines were drawn on the same graph.
Einthoven probably chose the initial letter P to follow the example set by
Descartes in geometry. When a more precise waveform was obtained
using the string galvanometer, which matched the corrected capillary
electrometer waveform, he continued to use the letters P, Q, R, S, and T,
and these letters are still in use today. Einthoven also described the
electrocardiographic features of a number of cardiovascular disorders. In
1924, he was awarded the Nobel Prize in Medicine for his discovery.
By 1927, General Electric had developed a portable apparatus that could
produce electrocardiograms without the use of the string galvanometer.
This device instead combined amplifier tubes similar to those used in a
radio with an internal lamp and a moving mirror that directed the tracing
of the electric pulses onto film. In 1937, Taro Takemi invented a new
portable electrocardiograph machine. Though the basic principles of that
era are still in use today, many advances in electrocardiography have been
made over the years. Instrumentation has evolved from a cumbersome
laboratory apparatus to compact electronic systems that often include
computerized interpretation of the electrocardiogram. In September 2018,
Apple Inc., introduced the Apple Watch Series 4, with a built-in titanium
electrode in the digital crown and the sapphire crystal electronic heart
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sensor, which allows the watch to give a single lead electrocardiogram
using only the watch interface.

WORKING OF ECG

An electrocardiograph is a machine that is used to perform

electrocardiography, and produces the electrocardiogram. The first
electrocardiographs are discussed later and are electrically primitive
compared to today's machines.
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The fundamental component to an ECG is the instrumentation amplifier,
which is responsible for taking the voltage difference between leads (see
below) and amplifying the signal. ECG voltages measured across the
body are on the order of hundreds of microvolts up to 1 millivolt (the
small square on a standard ECG is 100 microvolts). This low voltage
necessitates a low noise circuit and instrumentation amplifiers.
Early ECGs were constructed with analogue electronics and the signal
could drive a motor to print the signal on paper. Today,
electrocardiographs use analogue-to-digital converters to convert to a
digital signal that can then be manipulated with digital electronics. This
permits digital recording of ECGs and use on computer.

There are other components to the ECG:

 Safety features that include voltage protection for the patient and
operator. Since the machines are powered by mains power, it is
conceivable that either person could be subjected to voltage
capable of causing death. Additionally, the heart is sensitive to the
AC frequencies typically used for mains power (50 or 60 Hz).
 Defibrillation protection: any ECG used in healthcare may be
attached to a person who requires defibrillation and the ECG
needs to protect itself from this source of energy.
 Electrostatic discharge is similar to defibrillation discharge and
requires voltage protection up to 18,000 volts.
 Additionally circuitry called the right leg driver can be used to
reduce common-mode interference (typically the 50 or 60 Hz
mains power).

The typical design for a portable ECG is a combined unit that includes a
screen, keyboard, and printer on a small wheeled cart. The unit connects
to a long cable that branches to each lead and attaches to a conductive pad
on the patient. The ECG may include a rhythm analysis algorithm that
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produces a computerized interpretation of the ECG. The results from
these algorithms are considered "preliminary" until verified and/or
modified by someone trained in interpreting ECGs. Included in this
analysis is computation of common parameters that include PR interval,
QT interval, corrected QT (QTc) interval, PR axis, QRS axis, and more.
Earlier designs recorded each lead sequentially but current designs
employ circuits that can record all leads simultaneously. The former
introduces problems in interpretation since there may be beat-to-beat
changes in the rhythm, which makes it unwise to compare across beats.
More recent advancements in electrocardiography include work in
diminishing the size of the unit to make it more portable and therefore
more accessible to larger groups of patients. To achieve this, these smaller
devices rely on only two electrodes which together deliver "lead
I" of the standard ECG.

BASICS OF ECG

Electrodes are the actual conductive pads attached to the body surface.
Any pair of electrodes can measure the electrical potential difference
between the two corresponding locations of attachment. Such a pair forms
a lead. However, "leads" can also be formed between a physical electrode
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and a virtual electrode, known as the Wilson's central terminal, whose
potential is defined as the average potential measured by three limb
electrodes that are attached to the right arm, the left arm, and the left foot,
respectively. Commonly, 10 electrodes attached to the body are used to
form 12 ECG leads, with each lead measuring a specific electrical
potential difference (as listed in the table below). Leads are broken down
into three types: limb; augmented limb; and precordial or chest. The 12-
lead ECG has a total of three limb leads and three augmented limb leads
arranged like spokes of a wheel in the coronal plane (vertical), and six
precordial leads or chest leads that lie on the perpendicular transverse
plane (horizontal).

Limb leads: Leads I, II and III are called the limb leads. The electrodes
that form these signals are located on the limbs – one on each arm and one
on the left leg. The limb leads form the points of what is known as
Einthoven's triangle.

Precordial leads: The precordial leads lie in the transverse (horizontal)

plane, perpendicular to the other six leads. The six precordial electrodes
act as the positive poles for the six corresponding precordial leads: (V1, V2,
V3, V4, V5 and V6). Wilson's central terminal is used as the negative pole.

Lead locations on an ECG report: A standard 12-lead ECG report (an

electrocardiograph) shows a 2.5 second tracing of each of the twelve
leads.

DIFFERENT TYPES OF WAVES

Feature Description Pathology Duration

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P wave The P wave represents depolarization of
the atria. Atrial depolarization spreads
from the SA node towards the AV node,
and from the right atrium to the left atrium
PR The PR interval is measured from the
interval beginning of the P wave to the beginning
of the QRS complex. This interval reflects
the time the electrical impulse takes to
travel from the sinus node through the AV
node.
QRS The QRS complex represents the rapid
complex depolarization of the right and left
ventricles. The ventricles have a large
muscle mass compared to the atria, so
the QRS complex usually has a much
larger amplitude than the P wave.
QRS
ST The ST segment connects the QRS
segment complex and the T wave; it represents the
period when the ventricles are
depolarized.
T wave The T wave represents the repolarization
of the ventricles. It is generally upright in
all leads except aVR and lead V1
Corrected The QT interval is measured from the
QT beginning of the QRS complex to the end
interval of the T wave. Acceptable ranges vary
with heart rate, so it must be corrected to
(QTc)
the QTc by dividing by the square root of
the RR interval.
U wave The U wave is hypothesized to be caused
by the repolarization of the
interventricular septum. It normally has a
low amplitude, and even more often is
completely absent.
The P wave is typically upright in most 80 ms
leads except for AVR; an unusual P wave
axis (inverted in other leads) can indicate
an ectopic atrial pacemaker. If the P wave
is of unusually long duration, it may
represent atrial enlargement. Typically a
large right atrium gives a tall, peaked P
wave while a large left atrium gives a two
humped bifid P wave.
A PR interval shorter than 120 ms 120 to
suggests that the electrical impulse is 200 ms
bypassing the AV node, as in Wolf
Parkinson-White syndrome. A PR interval
consistently longer than 200 ms
diagnoses first degree atrioventricular
block. The PR segment (the portion of the
tracing after the P wave and before the
QRS complex) is typically completely flat,
but may be depressed in pericarditis.
If the QRS complex is wide (longer than 80 to 100
120 ms) it suggests disruption of the ms
heart's conduction system, such as in
LBBB, RBBB, or ventricular rhythms such
as ventricular tachycardia. Metabolic
issues such as severe hyperkalaemia or
tricyclic antidepressant overdose can also
widen the QRS complex. An unusually tall
complex may represent left
ventricular hypertrophy while a very low
amplitude QRS complex may represent a
pericardial effusion or infiltrative
myocardial disease.
It is usually isoelectric, but may be
depressed or elevated with myocardial
infarction or ischemia. ST depression can
also be caused by LVH .
Inverted T waves can be a sign of 160 ms
myocardial ischemia, left ventricular
hypertrophy, high intracranial pressure, or
metabolic abnormalities. Peaked T waves
can be a sign of hyperkalaemia or very
early myocardial infarction
A prolonged QTc interval is a risk factor for 440 ms
ventricular tachyarrhythmia’s and sudden
death. Long QT can arise as a genetic
syndrome, or as a side effect of certain
medications. An unusually short QTc
can be seen in severe hypercalcemia.
If the U wave is very prominent, ,
hypercalcemia or hyperthyroidism.
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ECG
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HEXAXIAL REFERENCE SYSTEM

The hexaxial reference system consists of 6 dissecting lines each

representing one of the limb leads of the heart. It also consists of a circle
which represents the heart. The intersection of these lines divides the
circle into equal 30 degrees segments with 0 degrees appearing at 3
o'clock. Moving counter-clockwise around the circle the degrees
becomes increasingly negative until it reaches +/-180 degrees at the 9
o'clock position. The bottom half of the circle contains the corresponding
positive degrees.

From this hexaxial diagram we will be able to identify the 6 limb leads of
the frontal plane and what area of the heart they are looking at. Key points
to remember:
1. The electrical pathway normally travels from top to bottom and right
to left.
2. The electrical current travels from negative to positive.

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 AXIS DETERMINATION
The axis of the ECG is the major direction of the overall electrical activity
of the heart. It can be normal, leftward (left axis deviation, or LAD),
rightward (right axis deviation, or RAD) or indeterminate (northwest
axis). The QRS axis is the most important to determine. However, the P
wave or T wave axis can also be measured.

To determine the QRS axis, the limb leads (not the precordial leads) need
to be examined. The depiction of the standard leads and their relationship
to the cardiac axis is below.

The normal QRS axis should be between -30 and +90 degrees. Left axis
deviation is defined as the major QRS vector, falling between -30 and 90
degrees. Right axis deviation occurs with the QRS axis and is between
+90 and +180 degrees. Indeterminate axis is between +/- 180 and -90
degrees.

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Normal QRS Axis

If the QRS complex is upright (positive) in both lead I and lead aVF, then
the axis is normal. The image below demonstrates this example, with the
electrical vector heading towards the positive of lead I and the positive of
lead AVF, as indicated by the arrows. The QRS axis is thus between these
two arrows, which falls within the normal range.

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 Left Axis Deviation

If the QRS is upright in lead I (positive) and downward in lead AVF

(negative), then the axis is between 0 and -90 degrees. However, recalling
that left axis deviation is defined as between -30 and -90, this scenario is
not always technically left axis deviation. In this scenario, the QRS axis
could fall between 0 and -30, which is within normal limits. To further
distinguish normal from left axis deviation in this setting, look at lead II.
If lead II is downward (negative), then the axis is more towards -120, and
left axis deviation is present. If the QRS complex in lead II is upright
(positive), then the axis is more towards +60 degrees, and the QRS axis
is normal.

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Right Axis Deviation

If the QRS is predominantly negative in lead I and positive in lead AVF,

then the axis is rightward (right axis deviation).

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Indeterminate Axis

If the QRS is downward (negative) in lead I and downward (negative) in

lead AVF, then the axis is indeterminate and sometimes referred to as
“north-western axis.” This finding is uncommon and usually from
ventricular rhythms; however, it can also be from paced rhythms, lead
misplacement and certain congenital heart diseases.

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Medical uses of ECG
The overall goal of performing an ECG is to obtain information about the
structure and function of the heart. Medical uses for this information are
varied and generally need knowledge of the structure and/or function of
the heart to be interpreted. Some indications for performing an ECG
include:

 Suspected myocardial infarction (heart attack) or chest pain.

 Suspected pulmonary embolism or shortness of breath.
 A third heart sound, fourth heart sound, a cardiac murmur or other
findings suggestive of a structural heart disease.
 Perceived arrhythmia either by pulse or palpitations.
 Monitoring of known cardiac arrhythmias.
 Fainting or collapse.
 Seizures.
 Monitoring the effects of a medication on the heart (e.g. drug
induced QT prolongation).
 Assessing severity of electrolyte abnormalities, such as
Hyperkalaemia.
 Hypertrophic cardiomyopathy screening in adolescents as part of a
sports physical out of concern for sudden cardiac death.
 Perioperative monitoring in which any form of anaesthesia is
involved (e.g. monitored anaesthesia care, general anaesthesia);
typically both intraoperative and postoperative.
 Cardiac stress testing.
 Computed tomography angiography (CTA) and magnetic
resonance angiography (MRA) of the heart (ECG is used to "gate"
the scanning so that the anatomical position of the heart is steady).

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  Biotelemetry of patients for any of the above reasons and such
monitoring can include internal and external defibrillators and
pacemakers.

CONCLUSION

The proposed and developed system performs analysis of various ECG

signals and evaluates the person's stress level. The system is developed
in such a way so as to handle normal as well as abnormal cardiac
conditions. The extracted features are compared with the expert rules
which help in determining the risk of stress level of the patient. The
person as well as the doctor will be at ease as the device is portable and
handy. Future developments of the developed system will transfer the
data to the remote PC or remote server. The results of ECG as well as
EEG signal of same person can be combined in order to decide the levels
of stress. Also different types of depression in a person like Major
Depression, Atypical Depression, Psychotic Depression, Dysthymia and
Manic Depression can be determined in the future. The system may be
applied to different fields for welfare of the common.

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BIBLIOGRAPHY

 www.wikilectures.com
 http://slideshare.com
 From books such as:
NCERT biology
Trueman’s Elementary Biology

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