The normal electrocardiogram

Toni Mustahsani Aprami

Department Of Cardiology and Vascular Medicine,
Padjadjaran University School of Medicine
Hasan Sadikin Hospital Bandung

Introduction

LA
RA

(HB)

(SAN
)
VV

(AVN
)

(BB)
HB
SAN

RA

AVN

LA

BB

(BB)

Terms describing cardiac cycle

Electrical

Mechanical

Systole

Diastole

Activation

Recovery

Excitation

Recovery

Depolarization

Repolarization

Shortening

Lengthening

Contraction

Relaxation

Emptying

Filling

Cardiac Electrical Activity

Mechanical Actiyity

What medical problems can be

diagnosed with an ECG?
Enlargement of cardiac chambers
Hypertrophy of cardiac muscle
Cardiac arrhythmias
Insufficient coronary blood flow
Death of heart muscle and its location
Electrolyte abnormality

Recording the electrocardiogram

RECORDING ELECTRODES AND LEADS

1. Bipolar limb leads:
record the potential differences between two limbs

2. Unipolar precordial leads:

record the absolute electrical potential at each of
designated torso sites

3. Augmented unipolar limb leads:

is designed to increase the amplitude of the output
of limb leads

BIPOLAR LIMBS LEADS

Lead I

Left arm

Lead II

Left leg

Lead III

Left leg

Positive
input

AUGMENTED UNIPOLAR LIMBS LEADS

aVR

Right arm

aVL

Left arm

aVF

Left leg

Positive
input

PRECORDIAL LEADS
V1

Right sternal margin, 4th intercostal space

V2

Left sternal margin, 4th intercostal space

V3

Midway between V2 and V4

V4

Left midclavicular line, 5th intercostal space

V5

Left anterior axillary line

V6

Left midaxillary line

Paper speed
25
mm/second
50

Reading the electrocardiogram

Normal features of the electrocardiogram.

What does an ECG actually measure?

An ECG records voltage on its vertical
axis against time on its horizontal axis
Measurement
indicates

along

the

summation

of

vertical
the

axis

electrical

activation of all of the cardiac cells

Measurement

along

the

horizontal

axis

indicates heart rate, regularity, and the time

intervals required for electrical activity to
move from one part of the heart to another

Systematic evaluation of the ECG

1. Rhythm
2. Rate and regularity
3. Axis
4. P-wave morphology
5. PR interval
6. QRS-complex morphology
7. ST-segment morphology
8. T-wave morphology
9. QTc interval

Q
R

S
R
R

QS

The normal cardiac

rhythm:
The sinus rhythm

 The normal cardiac rhythm is called sinus rhythm

because it is produced by electrical impulses formed
within the SA node
Sinus rhythm is essentially but not absolutely regular
The P-wave axis of sinus rhythm is between 300 and 750
An abnormal P-wave axis is usually accompanied with an
abnormally short PR interval. However, a short PR interval
with in the presence of normal P-wave axis suggests an
abnormal conduction pathway

Rate and regularity

P waves and QRS complexes are used to determine

cardiac rate and regularity
Over a particular interval of time, normally, there are same
numbers of P waves and QRS complexes
Heart rate:
* 1500 divided by number of small squares
between successive P waves or QRS complexes
* 300 divided by number of large squares
between successive P waves or QRS complexes
Normal heart rate: 60-100 beats per minute (bpm)

Axis of QRS Complex

 Normal axis:
between 30 degrees and +90 degrees
Right axis deviation (RAD):
between +90 degrees and 180 degrees
Left axis deviation (LAD):
between 30 degrees and 120 degrees

1200

aVR

-90
0

-600

1500

-300 aVL

1800

00
300

150 0

1200

III

90

aVF

60
0

II

Negative in lead I
Positive in lead aVF

Right axis deviation

(RAD)

Positive in lead I
Negative in lead aVF

Left axis deviation

(LAD)

P-wave morphology

1. The contour: is normally smooth and monophasic

(entirely positive or negative) in all leads except V1 or
occasionally V2
2. Upright or positive P waves are normally seen in leads I,
II, aVL, aVF, V4-V6 and downward in lead aVR. P wave
in lead III may be either upright or downward.
3. P-wave duration is normally less than 0.12 seconds
4. The maximal amplitude is normally no more than 0.2 mv

Abnormal P waves

The PR interval

1. The PR interval measures the time required for an

electrical impulse to travel from the atrial myocardium
adjacent to the SA node to the ventricular myocardium
adjacent to the fibers of the Purkinye network
2. The duration is normally from 0.11 to 0.20 seconds
3. PR interval varies with the heart rate. The faster the
heart rate, the shorter the PR interval

Abnormal PR interval

Morphology of the QRS

complex

1. Q waves
The presence of Q waves in leads V1, V2, and V3
should be consider abnormal.

The absence of small Q waves in leads V5 and V6

should be consider abnormal

A Q wave of any size is normal in leads III and

avR
In all other leads, a normal Q wave would be very
small (less than 0.04 second and its voltage is less
than 25% of the R-wave)

Abnormal Q waves

Abnormal Q waves

2. R waves
The positive R wave normally increases in amplitude and duration
from lead V1 to V4 or V5.
Loss of normal R-wave progression is considered abnormal

3. S wave
S wave should be large in V1 and then progressively smaller to V6

4. Ratio of R/S
Amplitude in V1 and V2 is normally less than 1.
R in V5 or V6 + S in V1 or V2 is not more than 35 mm

Abnormal R wave in V1

5. Duration of the QRS complex (QRS interval)

It normally ranges from 0.07 second to 0.11 second (less than
0.12 second). The QRS interval has no lower limit that indicates
abnormality
6. Amplitude of QRS complex
There is no arbitrary upper limit for normal voltage of the QRS
complex. An abnormally low QRS complex when the amplitude
is no more than 0.5 mV in any limb leads and no more than 1.0
mV in any of the precordial leads

Abnormal QRS interval

0.19
s

Morphology of the ST
segment

1. The ST segment represents the period during which the

ventricular myocardium remains in an activated or depolarized
state
2. ST segment normally located at the same horizontal level with
the PR segment
3. Normal variations:
Slight upsloping, downsloping, or horizontal depresion
Early repolarization : displacement of ST segment by as much
as 0.1 mV in the direction of the ensuing T wave
4. ST segment may be altered when there is prolonged QRS
complex

Normal ST segment

Normal ST-segment deviation

Morphology of the T
and
U waves

The T wave

The T waves are positively directed in all leads except

aVR (negative) and V1 (biphasic)

T waves do not normally exceed 0.5 mV in any limb

lead or 1.5 mV in any precordial lead

The U wave
U wave is either absent or present as a small wave
following the T wave and is usually most prominent in
leads V1 and V2. Increased prominence of the U wave
indicates the possibility of hypokalemia

The QTc interval

1. The QT interval measures the duration of electrical

activation and recovery of the ventricular myocardium
2. The QT interval decreases as the heart rate increases and
therefore should be corrected for cardiac rate (QTc
interval)
3. QTc= QT/RR interval (in seconds)
The upper limit of QTc is 0.46 second (slightly longer in
females)
4. QT interval varies among different leads. The longest QT
interval measured in multiple leads should therefore be
considered the true QT interval

Thank You

Excitation of the Heart

Excitation of the Heart

What is an Electrocardiogram ?
An ECG is the recording (gram) of the
electrical activity (electro) of the cells
of the heart (cardio) that reaches the
body surface

Initiates the heart muscle to contract, to

pump blood to the tissues

Electrical activity of the heart

Resting cells

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

Depolarizing cell

+
+
+ + +
+
+

+
+

+
+

+
+

+
+

Depolarized cells

+ + +

+ + +

+ + +

+ + +

Depolarized cells

+ + +

+ + +

+ + +

+ + +

Repolarizing cell

+ + +

+
+

+
+

+ + +

+ + +

Repolarized cells

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+ + +