CHAPTER 5

Electrical Axis and Axis

Deviation

Normal ECG patterns in the chest and extremity As noted in Chapter 3, each lead has a positive
leads were discussed in Chapter 4. The general and negative pole (see Fig. 5-1C). As a wave of depo-
terms horizontal heart (or horizontal QRS axis) and ver- larization spreads toward the positive pole, an
tical heart (or vertical QRS axis) were used to describe upward (positive) deflection occurs. As a wave
the normal variations in QRS patterns seen in the spreads toward the negative pole, a downward
extremity leads. In this chapter the concept of elec- (negative) deflection is inscribed.
trical axis is refined, and methods are presented for Finally, a scale is needed to determine or calcu-
estimating the QRS axis quickly and simply. late the mean QRS axis. By convention the positive
pole of lead I is said to be at 0°. All points below the
MEAN QRS AXIS: DEFINITION lead I axis are positive, and all points above that axis
The depolarization stimulus spreads through the are negative (Fig. 5-2). Thus, toward the positive
ventricles in different directions from instant to pole of lead aVL (–30°), the scale becomes negative.
instant. For example, it may be directed toward Downward toward the positive poles of leads II, III,
lead I at one moment and toward lead III the next. and aVF, the scale becomes more positive (lead II at
The mean direction of the QRS complex, or mean +60°, lead aVF at +90°, and lead III at +120°).
QRS electrical axis, can also be described. If you The completed hexaxial diagram used to mea-
could draw an arrow to represent the overall, or sure the QRS axis is shown in Figure 5-2. By con-
mean, direction in which the QRS complex is vention again, an electrical axis that points toward
pointed in the frontal plane of the body, you would lead aVL is termed leftward or horizontal. An axis
be drawing the electrical axis of the QRS complex. that points toward leads II, III, and aVF is rightward
The term mean QRS axis therefore describes the or vertical.
general direction in the frontal plane toward which
the QRS complex is predominantly pointed. MEAN QRS AXIS: CALCULATION
Because the QRS axis is being defined in the fron- In calculating the mean QRS axis, you are answer-
tal plane, the QRS is being described only in refer- ing this question: In what general direction or
ence to the six extremity leads (the six frontal plane toward which lead axis is the QRS complex predom-
leads). Therefore, the scale of reference used to mea- inantly oriented? In Figure 5-3, for example, notice
sure the mean QRS axis is the diagram of the frontal the tall R waves in leads II, III, and aVF. These waves
plane leads (described in Chapter 3 and depicted indicate that the heart is electrically vertical (vertical
again in Fig. 5-1). Einthoven’s triangle can easily be electrical axis). Furthermore, the R waves are equally
converted into a triaxial lead diagram by having the tall in leads II and III.* Therefore, by simple inspec-
axes of the three standard limb leads (I, II, and III) tion the mean electrical QRS axis can be seen to be
intersect at a central point (Fig. 5-1A). Similarly the directed between the positive poles of leads II and
axes of the three augmented limb leads (aVR, aVL, III and toward the positive pole of lead aVF (+90°).
and aVF) also form a triaxial lead diagram (Fig. As a general rule, the mean QRS axis points
5-1B). These two triaxial lead diagrams can be com- midway between any two leads that show tall R
bined to produce a hexaxial lead diagram (Fig. 5-1C). waves of equal height.
You will be using this diagram to determine the
mean QRS axis and describe axis deviation.
*In Figure 5-3, three leads (II, III, and aVF) have R waves of equal
height. In this situation the electrical axis points toward the middle
Please go to expertconsult.com for supplemental chapter material. lead (i.e., toward lead aVF or at +90°).

35
36   PART I  Basic Principles and Patterns

II III aVF

aVR aVL

I I

aVL aVR

A III II B aVF

aVF
II III

aVR aVL

I I

aVL aVR

III II
C aVF

Figure 5-1. A, Relationship of leads I, II, and III. B, Relationship of leads aVR, aVL, and aVF. C, These diagrams have been com-
bined to form a hexaxial lead diagram. Notice that each lead has a positive and negative pole. The negative poles are designated by
dashed lines.

90° In Figure 5-3 the mean electrical axis could have

120° aVF 60° been calculated a second way. Recall from Chapter
II III 3 that if a wave of depolarization is oriented at right
150° 30° angles to any lead axis, a biphasic complex (RS or
aVR aVL QR) is recorded in that lead. Reasoning in a reverse
manner, if you find a biphasic complex in any of the
extremity leads, the mean QRS axis must be directed
180° I I 0° at 90° to that lead. Now look at Figure 5-3 again.
Do you see any biphasic QRS complexes? Obvi-
ously, lead I is biphasic and shows an RS pattern.
aVL aVR Therefore, the mean electrical axis must be directed
150° 30° at right angles to lead I. Because lead I on the hex-
axial lead scale is at 0°, the mean electrical axis must
III II
120° aVF 60°
be at right angles to 0° or at either –90° or +90°. If
90° the axis were –90°, the depolarization forces would
be oriented away from the positive pole of lead aVF
Figure 5-2. In the hexaxial lead diagram, notice that each lead
has an angular designation, with the positive pole of lead I at
and that lead would show a negative complex. In
0°. All leads above lead I have negative angular values, and the Figure 5-3, however, lead aVF shows a positive com-
leads below it have positive values. plex (tall R wave); therefore the axis must be +90°.
 Chapter 5  Mean QRS Axis: Calculation   37

I II III aVR aVL aVF

R R

150° 30°
aVR aVL

I 0°

III II
120° 60°
aVF

Figure 5-3. Mean QRS axis of +90° (see text).

Figure 5-4 presents another example. By inspec- must be oriented toward lead II, which shows a
tion the mean QRS axis is obviously horizontal, relatively tall R wave.
because leads I and aVL are positive and leads II, A second general rule can now be given: The
III, and aVF are predominantly negative. The pre- mean QRS axis is oriented at right angles to any
cise electrical axis can be calculated by looking at lead showing a biphasic complex. In this situation
lead II, which shows a biphasic RS complex. There- the mean QRS axis points in the direction of leads
fore the axis must be at right angles to lead II. showing tall R waves.
Because lead II is at +60° on the hexaxial scale (see Still another example is provided in Figure 5-6.
Fig. 5-2), the axis must be either –30° or +150°. If The electrical axis is seen to be oriented away from
it were +150°, leads II, III, and aVF would be posi- leads II, III, and aVF and toward leads aVR and aVL,
tive. Clearly the axis is –30°. which show positive complexes. Because the R waves
Another example is given in Figure 5-5. The are of equal magnitude in leads aVR and aVL, the
QRS complex is positive in leads II, III, and aVF. axis must be oriented precisely between these leads,
Therefore the axis is relatively vertical. Because the or at –90°. Alternatively, look at lead I, which shows
R waves are of equal magnitude in leads I and III, a biphasic RS complex. In this case the axis must be
the mean QRS axis must be oriented between these directed at right angles to lead I (0°); that is, it must
two leads, or at +60°. be either –90° or +90°. Because the axis is oriented
Alternatively, in Figure 5-5 the QRS axis can away from the positive pole of lead aVF and toward
be calculated by looking at lead aVL, which the negative pole of that lead, it must be –90°.
shows a biphasic RS-type complex. The axis must Again, look at Figure 5-7. Because lead aVR
be at right angles to lead aVL (–30°); that is, it shows a biphasic RS-type complex, the electrical
must be oriented at either –120° or +60°. Obvi- axis must be at right angles to the axis of that lead.
ously, the axis is at +60°, since the electrical axis The axis of aVR is at –150°; therefore, the electrical
38   PART I  Basic Principles and Patterns

I II III aVR aVL aVF

150° 30°
aVR aVL

I 0°

III II
120° 60°
aVF

Figure 5-4. Mean QRS axis of −30° (see text).

I II III aVR aVL aVF

150° 30°
aVR aVL

I 0°

III II
120° 60°
aVF

Figure 5-5. Mean QRS axis of +60° (see text).

 Chapter 5  Axis Deviation   39

I II III aVR aVL aVF

150° 30°
aVR aVL

I 0°

III II
120° 60°
aVF

Figure 5-6. Mean QRS axis of −90° (see text).

axis in this case must be either –60° or +120°. In summary, the mean QRS axis can be deter-
Clearly it is –60° because lead aVL is positive and mined on the basis of one or both of the following
lead III shows a negative complex.*
•
rules:
These basic examples should establish the The mean QRS axis points midway between the
ground rules for calculating the mean QRS axis. axes of two extremity leads that show tall R

•
However, such calculations are generally only an waves of equal amplitude.
estimate or a near approximation. An error of 10° The mean QRS axis points at 90° (right angles)
or 15° is not clinically significant. Thus it is per- to any extremity lead that shows a biphasic (QR
fectly acceptable to calculate the axis from leads in or RS) complex and in the direction of leads that
which the QRS complex is nearly biphasic or from show relatively tall R waves.
two leads in which the R (or S) waves are of approx-
imately equal amplitude.† AXIS DEVIATION
The mean QRS axis is a basic measurement that
should be made on every ECG. In the ECGs of
*In
most normal people this axis lies between –30°
Figure 5-7 the QRS axis can also be calculated by looking at lead I,
which shows an R wave of equal amplitude with the S wave in lead and +100°. An axis of –30° or more negative is
II. The mean QRS axis must be oriented between the positive pole of described as left axis deviation (LAD), and one that is
lead I (0°) and the negative pole of lead II (−120°). Therefore, the +100° or more positive is termed right axis deviation
axis must be at −60°.
†For example, when the R waves in two leads have similar but not (RAD). In other words, LAD is an abnormal exten-
identical voltages, the mean QRS axis does not lie exactly between sion of the mean QRS axis found in persons with
these two leads. Instead, it points more toward the lead with the
larger amplitude. Similarly, if a lead shows a biphasic (RS-type)
an electrically horizontal heart, and RAD is an
deflection with the R and S waves not of identical amplitude, the abnormal extension of the mean QRS axis in per-
mean QRS axis does not point exactly perpendicular to that lead. If sons with an electrically vertical heart.
the R wave is larger than the S wave, the axis points slightly less than
90° away from the lead. If the R wave is smaller than the S wave, the The mean QRS axis is determined by the ana-
axis points slightly more than 90° away from that lead. tomic position of the heart and the direction in
40   PART I  Basic Principles and Patterns

I II III aVR aVL aVF

150° 30°
aVR aVL

I 0°

III II
120° 60°
aVF

Figure 5-7. Mean QRS axis of −60° (see text).

which the stimulus spreads through the ventricles Right Axis Deviation
(i.e., the direction of ventricular depolarization):
1. The influence of cardiac anatomic position on the I II III
electrical axis can be illustrated by the effects of R
respiration. When a person breathes in, the dia- R
phragm descends and the heart becomes more
vertical in the chest cavity. This change gener-
ally shifts the QRS electrical axis vertically (to
the right). (Patients with emphysema and
chronically hyperinflated lungs usually have
anatomically vertical hearts and electrically ver-
tical QRS axes.) Conversely, when the person
breathes out, the diaphragm ascends and the Figure 5-8. Right axis deviation (mean QRS axis more posi-
heart assumes a more horizontal position in the tive than +100) can be determined by inspecting leads I, II, and
chest. This generally shifts the QRS electrical III. Notice that the R wave is taller in lead III than in lead II.
axis horizontally (to the left).
2. The influence of the direction of ventricular depo- Recognition of RAD and LAD is quite simple:
larization can be illustrated by left anterior fas- 1. RAD exists if the QRS axis is found to be +100°
cicular block, in which the spread of stimuli or more positive. Recall that when leads II and
through the more superior and leftward por- III show tall R waves of equal height, the QRS
tions of the left ventricle is delayed and the axis must be +90°. As an approximate rule, if
mean QRS axis shifts to the left (see Chapter 7). leads II and III show tall R waves and the R wave
By contrast, with right ventricular hypertrophy in lead III exceeds the R wave in lead II, RAD is
(RVH) the QRS axis shifts to the right. present. In addition, lead I shows an RS pattern
 Chapter 5  Axis Deviation   41

Right Axis Deviation

I II III aVR aVL aVF

Figure 5-9. Notice the R waves in leads II and III, with the R wave in lead III being larger than the one in lead II, from a patient with
right axis deviation.

Left Axis Deviation lead I shows an RS-type complex in which the S

wave is deeper than the R wave is tall (see Figs.
I II III

•
5-8 and 5-9).
LAD is present if lead I shows a tall R wave, lead
III shows a deep S wave, and lead II shows either
r a biphasic RS complex (with the amplitude of
the S wave exceeding the height of the r wave)
(see Figs. 5-10 and 5-11) or a QS complex. Leads
I and aVL both show R waves.
In Chapter 4 the terms electrically vertical and elec-
S trically horizontal heart positions (mean QRS axes)
were introduced. This chapter has added the terms
left axis deviation and right axis deviation. What is the
Figure 5-10. Left axis deviation (mean QRS axis more nega- difference between these terms? Electrically vertical
tive than –30°) can be determined by simple inspection of leads and electrically horizontal heart positions are quali-
I, II, and III. Notice that lead II shows an rS complex (with the S
wave of greater amplitude than the r wave). tative. With an electrically vertical mean QRS axis,
leads II, III, and aVF show tall R waves. With an elec-
trically horizontal mean QRS axis, leads I and aVL
with the S wave deeper than the R wave is tall show tall R waves. With an electrically vertical heart,
(see Figs. 5-8 and 5-9). the actual mean QRS axis may be normal (e.g., +80°)
2. LAD exists if the QRS axis is found to be –30° or or abnormally rightward (e.g., +120°). Similarly,
more negative. In the ECG shown in Figure 5-4 with an electrically horizontal heart the actual axis
the QRS axis is exactly –30°. Notice that lead II may be normal (0°) or abnormally leftward (–50°).
shows a biphasic (RS) complex. Remember that RAD therefore is simply an extreme form of a
the location of lead II is aligned at +60° (see Fig. vertical mean QRS axis, and LAD is an extreme
5-2), and a biphasic complex indicates that the form of a horizontal mean QRS axis. Saying that a
electrical axis must be at right angles to that lead patient has an electrically vertical or horizontal
(at either –30° or +150°). Thus, with an axis of mean QRS axis does not, in fact, tell whether actual
–30°, lead II shows an RS complex with the R axis deviation is present.
and S waves of equal amplitude. If the electrical
axis is more negative than –30° (LAD), lead II Axis Deviation: Instant Recognition
shows an RS complex with the S wave deeper For beginning students, precise calculation of the
than the R wave is tall (Figs. 5-10 and 5-11). QRS axis is not as important as answering the fol-
The rules for recognizing QRS axis deviation lowing key questions: Is the QRS axis normal, or is

•
can be summarized as follows: LAD or RAD present? The answer can be obtained
RAD is present if the R wave in lead III is taller simply by inspecting the QRS complex from leads
than the R wave in lead II. Notice that with RAD, I and II (Fig. 5-12).
42   PART I  Basic Principles and Patterns

If the QRS complexes in both leads are positive, RAD or LAD is not necessarily a sign of
the axis must be normal. If the QRS complexes is s­ ignificant underlying heart disease. Nevertheless,
predominantly positive in lead I and negative in recognition of RAD or LAD (Fig. 5-12 and 5-13)
lead II, LAD is present. If the QRS complex is pre- often provides supportive evidence for LVH or
dominantly negative in lead I and positive in lead RVH, ventricular conduction disturbance (left
II, RAD (or at least borderline RAD) is present. anterior or posterior hemiblock), or another disor-
(Very rarely, the QRS will be predominantly nega- der (see Chapter 24).
tive in both leads I and II. In such unusual cases, Finally, the limits for LAD and RAD (–30° to
extreme right or left axis deviation will be +100°) used in this book are necessarily arbitrary.
present.) Some authors use different criteria (e.g., 0° to
+90°). These apparent discrepancies reflect the
Clinical Significance important fact that no absolute parameters have
Axis deviation may be encountered in a variety of been established in clinical electrocardiography—
settings. RAD, with a mean QRS axis +100° or only general criteria can be applied. The same
more, is sometimes seen in the ECGs of normal problems will be encountered in the discussion of
hearts. However, RVH is an important cause of LVH and RVH (see Chapter 6) because different
RAD (see Chapter 6). Another cause is myocardial
infarction of the lateral wall of the left ventricle. In Lead I Lead II
this setting, loss of the normal leftward depolariza-
tion forces may lead “by default” to a rightward
axis (see Fig. 8-11). Left posterior fascicular block
Normal
(hemiblock) is a much rarer cause of RAD (see
Chapter 7). The ECGs of patients with chronic
lung disease (emphysema or chronic bronchitis)
often show RAD. Finally, a sudden shift in the
mean QRS axis to the right (not necessarily caus- Left
ing actual RAD) may occur with acute pulmonary (LAD)
embolism (see Chapters 11 and 24).
LAD, with a mean QRS axis of –30° or more, is
also seen in several settings. Patients with left ven-
tricular hypertrophy (LVH) sometimes but not Right
(RAD)
always have LAD (see Chapter 6). Left anterior fas-
cicular block (hemiblock) is a fairly common cause
of marked deviation (more negative than –45°).
LAD may be seen in association with left bundle Figure 5-12. Simple method for telling whether the QRS axis
branch block (see Chapter 7). It may also occur in is normal using leads I and II. (LAD, left axis deviation; RAD,
the absence of apparent cardiac disease. right axis deviation.)

Left Axis Deviation

I II III aVR aVL aVF

Figure 5-11. Notice the rS complex in lead II, from a patient with left axis deviation.
 Chapter 5  Mean Electrical Axis of the P Wave and T Wave   43

voltage criteria have been described by various considered. The same principles can be applied to
authors. the mean electrical axes of the P wave and T wave in
On rare occasions, all six extremity leads show the frontal plane.
biphasic (QR or RS) complexes, which makes it For example, when sinus rhythm is present,
impossible to calculate the mean frontal plane the normal P wave is always negative in lead aVR
QRS axis. In such cases the term indeterminate axis and positive in lead II. Normally, therefore, the P
is used (Fig. 5-14). An indeterminate QRS axis may wave is generally directed toward the positive
occur as a normal variant, or it may be seen in a pole of lead II (see Fig. 4-3), which makes the nor-
variety of pathologic settings. mal mean P wave axis about +60°. On the other
hand, if the atrioventricular (AV) junction (and
not the sinus node) is pacing the heart, the atria
MEAN ELECTRICAL AXIS OF THE P are stimulated in a retrograde way. When AV
WAVE AND T WAVE junctional rhythm is present, atrial depolariza-
To this point, only the mean electrical axis of the tion spreads upward, toward lead aVR and away
QRS complex in the frontal plane has been from lead II (see Fig. 4-5). In this situation, lead
aVR may show a positive P wave and lead II a neg-
ative P wave, and the mean P wave axis may be
 90° about –150°.
The same principles can be used in calculating
the mean electrical axis of the T wave in the fron-
Left axis  30° tal plane. As a rule the mean T wave axis and the
Extreme axis deviation
deviation mean QRS axis normally point in the same gen-
(marked left eral (but not identical) direction. In other words,
or right axis) when the electrical position of the heart is hori-
 180° zontal, T waves normally are positive in leads I
Normal QRS
and aVL, in association with tall R waves in those
Right axis axis leads. When the electrical position is vertical, T
deviation waves are normally positive in leads II, III, and
aVF, in association with tall R waves in those
leads. (However, the T wave is often negative in
lead III normally, regardless of the electrical posi-
 100° tion of the heart.)
In summary, the concept of mean electrical axis
Figure 5-13. Normal QRS axis and axis deviation. Most can be applied to the QRS complex, P wave, or T
ECGs show either a normal axis or left or right axis deviation.
Occasionally the QRS axis is between –90° and 180°. Such an
wave. The mean electrical axis describes the general
extreme shift may be caused by marked left or right axis or overall direction of depolarization or repolariza-
deviation. tion in the frontal plane.

I II III aVR aVL aVF

Figure 5-14. Indeterminate axis. Notice the biphasic complexes (RS or QR) in all six frontal plane leads.