BASIC ELECTROCARDIOGRAPHY II.

CONDUCTION SYSTEM OF THE HEART

 A diagnostic exam to help in the diagnosis and management primarily of cardiac conditions  SINUS NODE
(others: renal, brain abnormality) o Main pacemaker of the heart
 Recording of the electrical activity of the heart o Dominant pacemaker since it is the fastest pacemaker
 The heart has its own electrical supply and supplied by the coronary arteries o Normal: 60-100 bpm
 REVIEW TEXT ALONG WITH PICTURES FOR BETTER UNDERSTANDING, ALL PICTURES ARE o Influenced by the ANS
MUST KNOWS  Increased sympathetic = increased HR; Vagal: Decreased HR
o Main blood supply: Left Coronary System and Right Coronary System
I. CELLULAR ELECTROPHYSIOLOGY
 ATRIOVENTRICULAR NODE
 Cardiac cells
o Normal: 40-60 bpm
o Electrically polarized cells at resting state
o Influenced by the ANS
o Mainly negatively charged inside, positively charged inside
o Main blood supply: Right Coronary Artery
o Resting Charge of about -90 mV
 `*if the sinus node dies, AV node will take over and fires a rate of 60 bpm
 Depolarization
 Electrical Conducting Cells
o Fundamental electrical event of the heart
o Hard wiring of the heart
o Cardiac cells lose their internal negativity
o Conduct current to the distant regions of the heart
 Excited portion of cardiac cells becomes more positive
o Atrial conducting system: Bachmann’s Bundle
o Propagated from one cell to another
 Supplies electricity at the atrioventricular node
o What happens is positive ions go inside the cell, and then it will depolarize the rest
o Ventricular conducting system: His Bundle which will be subdivided into:
of the cardiac cells, cardiac cells lose their internal negativity, it will proceed to
 Left and Right bundles
transfer to another cell until everything is depolarized
 While Left bundle is further subdivided into Anterior and
Posterior fascicles to the Purkinje system supplying the
 Repolarization
myocardial cells
o Restoration of polarity
o Returning of the negative charge inside the cell
 Myocardial cells
o Last one to be depolarized is the first one to repolarized o Contains abundant contractile proteins actin and myosin
o Contractile unit of the heart
o Current is spread across the entire myocardium
 If you put an electrode on one side of a cardiac cell, if the wave would proceed from here to o Contain pacemakers that fire at 30-45 bpm
that (+) electrode, on ECG you will see a positive deflection towards the electrode, if however o Activates when the pacemaker ability of the sinus and AV nodes as well as the
the wave of depolarization is opposite of that the electrode, on ECG you would appreciate a bundle branches, the ventricles will take over firing at 30-45 bpm
negative deflection.
 If the wave of depolarization start here going to this electrode, initially it will register a (+) III. ECG LIMB LEADS: Bipolar and Unipolar Limb Leads
deflection, at the point where it becomes perpendicular to the electrode, it will go back to  Bipolar Limb Leads
isoelectric level, if wave of depolarization go further, it becomes a negative deflection, so the o Consist of 2 electrodes placed at 2 different sites
end result you will have a biphasic wave (up and down) o Register the difference in potentials between these 2 sites
 Positive deflection: recording when the electric wave is TOWARDS the electrode o One electrode designated as positive, the other as negative
 Negative deflection: when the electric wave is going AWAY from the electrode  Unipolar Limb Leads
 Biphasic wave: if Perpendicular to the electrode; equal positive and negative deflections. o Measure the absolute electrical potential at one site relative to an electrode with
zero potential
 Placement of the Limb Leads
o Right Upper Extremity: RED
o Left Upper Extremity: YELLOW
o Right Lower Extremity: GROUND (“N”):
BLACK
o Left Lower Extremity: GREEN

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO

 1. BIPOLAR LIMB LEADS 2. UNIPOLAR LIMB LEADS/ AUGMENTED LIMB LEADS
 aVR, aVL, aVF
LEAD In Reference to the Axial  Augmented as much as 50%
Reference System  Clockwise to Lead I: assigned as + charge
Lead I Measures electrical potential 0 degree placement  Counter clockwise to Lead i: assigned as – charge
between the LEFT ARM (+ charged)  represents frontal plane of the heart
and RIGHT ARM (- charged)
Direction depolarization is from LEAD PORTION OF THE HEART In Reference to the Axial
Right  Left Reference System
Lead II Measures electrical potential (+) 60 degrees placement from aVR Measures the potential of Views the RIGHT SIDE OF (-)150 degrees from Lead I
between LEFT FOOT (+) and RIGHT Lead I the R arm in reference of a THE HEART
ARM (-) (-) potential between the
Direction is Right  Down Left L arm and L foot
Lead III Measures electrical potential (+) 120 degree placement from aVL Measures between L arm LATERAL (-) 30 degrees from Lead I
between LEFT FOOT (+) and LEFT Lead I (+ charged) against the 0
ARM (-) potential between the R
Direction Left  Down LEFT arm and the L foot
aVF Measures the potential INFERIOR (+) 90 degrees from Lead I
 The 3 Bipolar Limb leads make up the Einthoven’s between the L foot against
Triangle 0 potential of the R arm
and L arm
 Axial Reference System: Represents the frontal
plane of the body LEADS VENTRICULAR REGION
o Lead I: 0 degree placement I, aVL Lateral
o Lead II: +60 degree placement from
II, III, aVF Inferior
Lead I
aVR Right
o Lead III: +120 degree from Lead I

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO

 ECG READING
3. PRECORDIAL LEADS (Coronal Plane of Heart)
-It is a step by step process or a systematic approach.. okay? ;D
 V1, V2, V3. V4, V5, V6 1. Standardization
 Represents the coronal plane of the heart 2. Regularity
 V3/V4 are designated as transition zones; here you see more or less equal?? R wave and S 3. Rhythm
wave 4. Rate
 Unipolar leads representing the coronal plane of the heart 5. Axis
 Can represent whole anterior portion of the heart 6. Interval
 V1- V6 are all postoively charged 7. Hypertrophies/Enlargement
8. Ischemia/ Infarction
9. Miscellaneous

1. STANDARDIZATION

 An ECG strip has big and small squares

 X axis: Horizontal: Duration (time)
o Expressed in seconds
o 1 small square: 0.04 seconds
o 5 small squares: 0.2 seconds
o 1 big square: has 5 rows of small squares

 Y axis: Height: Amplitude (voltage)

o Expressed in millivolts (mV)
Placement of Precordial Leads o 1 small square: 1mm = 0.1 mV
Leads Placement o 5 small squares: 0.5 mV
V1 4th ICS, Right Parasternal border o 2 big squares: 1 mV
 Standard speed: 25 mm/s
V2 4th ICS, Left Parasternal border  Standard amplitude: 10 mm/mV
V3 Between V2 and V4
V4 5th ICS, Left Midclavicular Line
V5 5th ICS, Left Anterior Axillary Line
V6 5th ICS, Left Mid Axillary Line

Placement of the Precordial Leads in Relation to the Heart

PRECORDIAL LEADS VENTRICULAR REGION
V1-V2 Septal
V3-V4 Anterior
V5-V6 Lateral

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO

 5. AXIS
 Mean direction of vector Direction of vector for Atrial Depolarization
o R to L and slightly inferiorly (about 60 degrees from Lead I, direction going to Lead
2 thus a positive deflection)
o Lead II: + deflection in P wave since the wave of depolarization is towards Lead II
 1st portion of P wave: Right Atrial depolarization
 2nd portion of P wave: Left Atrial depolarization
o V1
 Going towards V1 so positive deflection and as it goes away from the
Waves (refer to table below) picture ng ecg tracing! left atrium, then it will register as a negative deflection: Biphasic P
wave
P wave Atrial Depolarization  Direction of vector for Ventricular Depolarization
QRS wave Ventricular Depolarization o Leftward and Inferiorly
o Depolarization of the rest of the ventricle, dominated by the left ventricle due to
T wave Ventricular Repolarization
its bigger muscle mass
*Ventricular Depolarization dominates Atrial  TO DETERMINE THE AXIS: LOOK AT LEAD I AND aVF compare it with QRS of the leads
Repolarization so it is not recorded
Q wave 1st negative deflection after P wave NORMAL AXIS -30 to +100 Lead I: UP/ Positive Deflection
aVF: UP
R wave 1st positive deflection after Q wave
RIGHT AXIS DEVIATION +100 to +180 Lead I: DOWN/ Negative Deflection
S wave 1st negative deflection after R wave
aVF: UP
LEFT AXIS DEVIATION -30 to -90 Lead I: UP
2. REGULARITY aVF: DOWN
 Is it regular or irregular?
EXTREME AXIS -90 to +180 Lead I: DOWN
 Look at the P wave and QRS aVF: DOWN
 P wave: distance of 1 P wave to another P wave and should be at least equal
o Normally may vary about 10% of each cycle
 QRS wave: should be fairly regular and look at their distances
 P wave is ALWAYS followed by QRS then T wave
 Caliper is used to measure distances in an ECG strip

3. RHYTHM
 We say it is from the Sinus Node if there is a P wave
 No P wave: Not from the sinus node
 Normal Report: Regular sinus rhythm

4. RATE
 Heart Rate: 1500/ # of small squares between 2
consecutive R waves
 Norma Heart Rate: 60-100 bpm
 Eyeball Method: Look at the 2 consecutive R waves. Count
the number of small boxes between the 2 consecutive R
waves
o 1 large square: 300 bpm
o 2 large squares: 150 bpm
o 3 large squares: 100 bpm
o 4 large squares: 75 bpm
o 5 large squares : 60 bpm

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO

 6. INTERVALS J point
 Junction between the end of S wave and the beginning of the ST segment. It is the basis of
P wave determining:
 Recording of Atrial Depolarization o ST elevation
 Normal Duration: should not go beyond than 0.12 secs or 3 small squares o ST depression
 Normal Amplitude: not more than 2.5 mV or 2 ½ small squares  Base level in PR segement
o Normal amplitude: 1 small square: 0.1 mV
T wave: Recording of Ventricular Repolarization
PR interval
 Measures the time from the start of Atrial Depolarization to the start of Ventricular U wave
Depolarization  Sometimes appreciated and Comes after T wave
 Start of P wave and start of QRS  5-25% the height of the T wave (usually <1.5 mm)
 Normal PR interval: 0.12-0.20 sec
QT interval
QRS Complex  Measures the time from the beginning of Ventricular Depolarization to the end of Ventricular
 Measures the duration of Ventricular Depolarization Repolarization
 Start of Q to end of S wave  Start of Q wave and end of T wave
 Normal : 0.08 to 0.10 secs  Normal: up to 0.44 secs
 Direction of vector of Ventricular Depolarization always starts at the center of the heart  Comprises 40% of the normal cardiac cycle
(septum)  Should not be occupying more than 40% of the RR interval
o Septal depolarization  QTc Interval
 L to R direction  Tachycardia (falsely short QT interval)or Bradycardia (falsely long Qt interval)
 Goes towards V1: (+) deflection  To correct the QT interval: use Bazett’s formula
 QS: registers (-) deflection  BAZETT’S FORMULA: QTc interval = QTa (actual) / square root of RR interval
o Depolarization of the rest of the Ventricles, dominated by the LV
 Leftward and inferiorly
 V1: (-) deflection  S wave
 V6: (+) deflection  R wave
o Leftward and inferiorly
 Goes away from V1: (-) deflection: designated as S wave
 Towards V6: (+) deflection: designated as R wave
 In V5 or V6: may appreciate a small q wave representing septal repolarization
 Lead aVR: Negative deflections
 Leads I, II, AVF: Positive deflections
 Considering the Precordial Leads:
o From V1 to V6, R wave is getting bigger which is referred to as R wave progression
representing LV depolarization
 S wave moving from V1 to V6, it wave gets smaller
 V3 sometimes V4: Transition Zones
o Equal + and - deflections
 Poor R wave progression
o R wave is not progressive as it should be

ST segment
 Measures the time from the end of the Ventricular Depolarization to the start of Ventricular
Repolarization
 End of S wave and beginning of T wave
 Physiologic Delay
o To allow the atria to finish contracting before the ventricles begin to contract

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO

 CARDIAC CYCLE
 Represents mechanical contraction of the heart
 Depolarization (Pwave) always comes first before mechanical contraction of the heart
o P wave

@kafcamagay

diannemillado med2016 | MEDICINE 2 (PART 1) BASIC ECG │ DR. CALIBUSO