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BasicsECGpedia

Basics
Introduction

Step1:Rhythm

Contents[hide]
1HowdoIbegintoreadanECG?

Author(s)

I.A.C.vanderBilt,MD

Moderator

I.A.C.vanderBilt,MD

Supervisor
somenotesaboutauthorship

2WhatdoestheECGregister?
3TheECGrepresentsthesumoftheactionpotentialsofmillionsofcardiomyocytes
4Theelectricdischargeoftheheart
5ThedifferentECGwaves
6ThehistoryoftheECG
7TheECGelectrodes
7.1TheExtremityLeads
7.2TheChestLeads
8ECGvariants
9ColorcodingoftheECGleads
10SpecialLeads
11Ladderdiagram
12TechnicalProblems
13References

HowdoIbegintoreadanECG?
ClickontheECGtoseeanenlargement.Wheredoyoustart
wheninterpretinganECG?
Onthetopleftarethepatient'sinformation,name,sexand
dateofbirth
AttherightofthatarebeloweachothertheFrequency,

AshortECGregistrationofnormal
heartrhythm(sinusrhythm)

theconductiontimes(PQ,QRS,QT/QTc),andtheheart
axis(Ptopaxis,QRSaxisandTtopaxis)
FarthertotherightistheinterpretationoftheECGwritten
(thismaybemissingina'fresh'ECG,butlaterthe

AnexampleofanormalECG.Click
ontheImageforanenlargement

interpretationofthecardiologistorcomputerwillbeadded)
Downleftisthe'paperspeed'(25mm/sonthehorizontalaxis),thesensitivity(10mm/mV)andthefilter'sfrequency(40Hz,filters
noisefromeg.lights).
Thereisacalibration.Atthebeginningofeveryleadisaverticalblockthatshowswithwhatamplitudea1mVsignalisdrawn.So
theheightanddepthofthesesignalsareameasurementforthevoltage.Ifthisisnotsetat10mm,thereissomethingwrong
withthemachinesetting.
FinallywehavetheECGleadsthemselves.Thesewillbediscussedbelow.
Notethatthelayoutisdifferentforeachmachine,butmostmachineswillshowtheinformationabovesomewhere.

WhatdoestheECGregister?
Theelectrocardiogram
Anelectrocardiogram(ECGorEKG)isaregisteroftheheart'selectricalactivity.
Justlikeskeletalmuscles,heartmusclesareelectricallystimulatedtocontract.Thisstimulationisalsocalledactivationorexcitation.
Cardiacmusclesareelectricallychargedatrest.Theinsideofthecellisnegativelychargedrelativetotheoutside(restingpotential).
Ifthecardiacmusclecellsareelectricallystimulated,theydepolarize(therestingpotentialchangesfromnegativetopositive)and
contract.Theelectricalactivityofasinglecellcanberegisteredastheactionpotential.Astheelectricalimpulsespreadsthroughthe
heart,theelectricalfieldchangescontinuallyinsizeanddirection.TheECGisagraphoftheseelectricalcardiacsignals.

TheECGrepresentsthesumoftheactionpotentialsofmillionsofcardiomyocytes
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Theheartconsistsofapproximately300billioncells

Inresttheheartcellsarenegativelycharged.Through
thedepolarizationbysurroundingcellstheybecome
positivelychargedandtheycontract.

softhecardiomyocytes

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Thismovieshowsthecontractionofasingle(rabbit)heartcell.Theglass
electrodemeasurestheelectricalcurrentintheheartcell(withthepatchclamp
method).Theelectricalsignaliswritteninblueandshowstheaction
potential.CourtesyofArieVerkerkandAntonivanGinneken,AMC,Amsterdam,
TheNetherlands.

Theindividualactionpotentialsoftheindividualcardiomyocytesareaveraged.Thefinalresult,whichisshownontheECG,is
actuallytheaverageofbillionsofmicroscopicelectricalsignals.
Duringthedepolarization,sodiumionsstreamintothecell.Subsequently,thecalciumionsstreamintothecell.Thesecalciumions
causetheactualmuscularcontraction.
Finallythepotassiumionsstreamoutofthecell.Duringrepolarizationtheionconcentrationreturnstoitsprecontractionstate.Onthe
ECG,anactionpotentialwavecomingtowardtheelectrodeisshownasapositive(upwards)signal.HeretheECGelectrodeis
representedasaneye.

Theelectricdischargeoftheheart
Thesinoatrialnode(SAnode)containsthefastestphysiologicalpacemakercellsofthehearttherefore,theydetermine
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Theconductionsystemoftheheart

theheartrate.Firsttheatriadepolarizeandcontract.Afterthat
theventriclesdepolarizeandcontract.Theelectricalsignalbetweentheatriaand
theventriclesgoesfromthesinusnodeviatheatriatotheAVnode(atrioventriculartransition)totheHisbundleandsubsequentlyto
therightandleftbundlebranches,whichendinadensenetworkofPurkinjefibers.Thedepolarizationoftheheartresultsinan
electricalforcewhichhasadirectionandmagnitudeanelectricalvector.Thisvectorchangeseverymillisecondofthedepolarization.
Intheanimationvectorsforatrialdepolarization,ventriculardepolarizationandventricularrepolarizationareshown.

ThedifferentECGwaves
ThePwaveistheresult
oftheatrial
depolarization.This
depolarizationstartsin
theSA(sinoatrial)node.
Thesignalproducedby
pacemakercellsinthe
SAnodeisconductedto
therightandleftatria.
Normalatrial
repolarizationisnot
visibleontheECG(but
canbevisible

TheQRScomplexisformedbythesumoftheelectric
avtivityoftheinner(endocardial)andtheouter
(epicardial)cardiomyocytes

duringatrial

TheoriginofthedifferentwavesontheECG

infarctionandpericarditis).
TheQRScomplexistheaverageofthedepolarizationwavesoftheinner
(endocardial)andouter(epicardial)cardiomyocytes.Astheendocardial
cardiomyocytesdepolarizeslightlyearlierthantheouterlayers,atypicalQRS
patternoccurs(figure).

ExampleofthedifferentQRSconfigurations

TheTwaverepresentstherepolarizationoftheventricles.Thereisno
cardiacmuscleactivityduringtheTwave.
Oneheartbeatconsistsofanatrialdepolarization>atrialcontraction>pwave,ventriculardepolarization>ventricular
contraction>ORScomplexandtherestingphase(includingtherepolarizationduringtheTwave)betweentwoheartbeats.
Havealookatthis[animationoftheheartcycle ]
TheoriginoftheUwaveisunknown.Thiswavepossiblyresultsfrom"afterdepolarizations"oftheventricles.
Theletters"Q","R"and"S"areusedtodescribetheQRScomplex
Q:thefirstnegativedeflectionafterthepwave.Ifthefirstdeflectionisnotnegative,theQisabsent.
R:thepositivedeflection
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S:thenegativedeflectionaftertheRwave
Smallprintletters(q,r,s)areusedtodescribedeflectionsofsmallamplitude.Forexample:qRS=smallq,tallR,deepS.
R`:isusedtodescribeasecondRwave(asinarightbundlebranchblock)
Seefigureforsomeexamplesofthis.

ThehistoryoftheECG
AconcisehistoryoftheECGispresentedinadifferentchapter.

TheECGelectrodes
Electricalactivitygoingthroughtheheartcanbemeasuredbyexternal(skin)electrodes.The
electrocardiogram(ECG)registerstheseactivitiesfromelectrodeswhichhavebeenattached
ontodifferentplacesonthebody.Intotal,twelveleadsarecalculatedusingtenelectrodes.
Thetenelectrodesare:
Thefourextremityelectrodes:
LAleftarm
RArightarm
Nneutral,ontherightleg(=electricalearth,orpointzero,towhichtheelectricalcurrent

Thelimbleads

ismeasured)
Ffoot,ontheleftleg
Itmakesnodifferencewhethertheelectrodesareattachedproximalordistalonthe
extremities.However,itisbesttobeuniforminthis.(eg.donotattachanelectrodeontheleft
shoulderandoneontherightwrist).
Thesixchestelectrodes:
V1placedinthe4thintercostalspace,rightofthesternum

Thechestleads

V2placedinthe4thintercostalspace,leftofthesternum
V3placedbetweenV2andV4
V4placed5thintercostalspaceinthenippleline.OfficialrecommendationsaretoplaceV4underthebreastinwomen.[1]
V5placedbetweenV4andV6
V6placedinthemidaxillarylineonthesameheightasV4(horizontallinefromV4,sonotnecessarilyinthe5thintercostal
space)

Withtheuseofthese10electrodes,12leadscanbederived.Thereare6extremityleadsand6precordialleads.

TheExtremityLeads
Theextremityleadsare:
Ifromtherighttotheleftarm
IIfromtherightarmtotheleftleg
IIIfromtheleftarmtotheleftleg
Aneasyruletoremember:leadI+leadIII=leadIIThisisdonewiththeuseoftheheightor
depth,independentofthewave(QRS,PofT).Example:ifinleadI,theQrScomplexis3mmin
heightandinleadIII9mm,theheightoftheQRScomplexinleadIIis12mm.
Otherextremityleadsare:
AVLpointstotheleftarm
AVRpointstotherightarm
AVFpointstothefeet
ThecapitalAstandsfor"augmented"andVfor"voltage".
(aVR+aVL+aVF=0)

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TheChestLeads
Theprecordial,orchestleads,(V1,V2,V3,V4,V5andV6)'observe'thedepolarizationwaveinthefrontalplane.
Example:V1isclosetotherightventricleandtherightatrium.Signalsintheseareasofthehearthavethelargestsignalinthislead.
V6istheclosesttothelateralwalloftheleftventricle.

ECGvariants
Besidesthestandard12leadECGacoupleofvariantsareinuse:
The3channelECGuses3or4ECGelectrodes.Redisontheright,yellowontheleftarm,greenontheleftleg('sunshineson
thegrass')andblackontherightleg.Thesebasicleadsyieldenoughinformationforrhythmmonitoring.FordeterminationofST
elevation,thesebasicleadsareinadequateasthereisnoleadthatgives(ST)informationabouttheanteriorwall.STchanges
registeredduring34channelECGmonitoringshouldpromptacquisitionofa12leadECG.
The5channelECGuses4extremitiyleadsand1precordiallead.ThisimprovesSTsegmentaccuracy,butisstillinferiortoa12
leadECG.[2][3]
InvectorelectrocardiographythemovementofelectricalacitivityoftheP,QRSandTwaveisdescribed.AdditionalX,YandZ
leadsarerecorded.Vectorelectrocardiographyisrarelyusednowadays,butissometimesusefulinaresearchsetting.
Inbodysurfacemappingseveralarraysareusedtoaccuratelymapthecardiacelectricalwavefrontasitmovesoverdebody
surface.Withthisinformationtheelectricalacitivityoftheheartcanbecalculated.Thisissometimesusedinaresearchsetting.

ColorcodingoftheECGleads
TwosystemsforECGleadcolorcodingareused:theAHA(AmericanHeartAssociation)systemandtheIEC(International
ElectrotechnicalCommission)system:

Location
RightArm
LeftArm
RightLeg
LeftLeg
Chest
Chest
Chest
Chest
Chest
Chest

AHA(AmericanHeartAssociation) IEC(InternationalElectrotechnicalCommission)
Inscription
Colour
Inscription
Colour
RA
White
R
Red
LA
Black
L
Yellow
RL
Green
N
Black
LL
Red
F
Green
V1
Brown/Red
C1
White/Red
V2
Brown/Yellow
C2
White/Yellow
V3
Brown/Green
C3
White/Green
V4
V5
V6

Brown/Blue
Brown/Orange
Brown/Purple

C4
C5
C6

White/Brown
White/Black
White/Violet

SpecialLeads
Throughouthistoryextra
leadpositionshavebeen
tried.Mostarerarelyused
inpractice,buttheycan
deliververyvaluable
diagnosticcluesinspecific
LeadsV7,V8andV9canbehelpful
inthediagnosisofposterior
ChangedleadpositionsofleadsV3
myocardialinfarction
andV5toincreasethesensitiviyto
'catch'aBrugadapatternonthe
ECG.

cases.
Leadstoimprovediagnosis
inrightventricularen
posteriorinfarction:
Incaseofaninferiorwall
infarct,extraleadsmaybe

used:

Apatientwithatrialfibrillationwitha
'LewisLead'positioningofthe
leads.Comparedwiththenormal
leadconfiguration,theatrialsignal
isenlarged.Althoughsomeparts
havea'sawtooth'appearance
consistentwithatrialflutter,the
rhythmisatrialfibrillationasthereis
achangingpatternintheatrial
activity.

1.OnarightsidedECG,V1andV2remainonthesameplace.V3toV6are
placedonthesameplacebutmirroredonthechest.SoV4isinthemiddleofthe
rightclavicle.TheECGshouldbemarkedasaRightsidedECG.V4R(V4but
rightsided)isasensitiveleadfordiagnosingrightventricularinfarctions.
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2.LeadsV7V8V9canbeusedtodiagnoseaposteriorinfarct.AfterV6,leads
areplacedtowardstheback.SeethechapterIschemiaforotherwaysof
diagnosingposteriorinfarction.

Leadstoimprovedetectionofatrialrhyhtm:
Inwidecomplextachycardia,gooddetectionofatrialrhythmandatrioventricular
dissociationcanbeveryhelpfulinthediagnosisprocess.AnesophagalECGelectrode
placedclosetotheatriacanbehelpful.Another,lessinvasive,methodistheLewisLead.
Thisisrecordedbychangingthelimbelectrodes,placingtherightarmelectrodeinthe
secondintercostalspaceandtheleftarmelectrodeinthefourthintercostalspace,both
totherightofthesternum.Furthermoregainisincreasedto20mm/mVandpaperspeed

Thesamepatientwithanormal
leadconfiguration.Therhythmis
atrialfibrillation.Theatrialactivityin
leadV1isorganizedprobablydue
toaorganisationofelectricalactivity
afteritenterstherightatrial
appendage,closetoleadV1.

to50mm/sec.[4]
LeadpositioningtoenhancedetectionofBrugadasyndrome

Ladderdiagram
Aladderdiagramisadiagramtoexplainarrhythmias.Thefigureshowsasimple
ladderdiagramfornormalsinusrhythm,followedbyavnodalextrasystole.The
originofimpulseformation(sinusnodeforthefirsttwobeatsandAVjunctionfor
thethirdbeat)andtheconductionintheheartareshown.

Aladderdiagramisadiagramthatshowsthe
presumedoriginofimpulseformationandconduction
intheheart.A=atrial,AV=AVnode,V=ventricles

TechnicalProblems
AlsoreadthechapteraboutTechnicalProblems.Thatwillhelpyourecognizeelectricaldisturbancesandleadreversals.

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