ECG For Beginners

ECG for Beginners-Part I
Rate, Rhythm and Axis
Aims
To provide an introduction to the basics
of the electrocardiogram and its
interpretation.
Learning objectives
By the end of the session the students
will be able to:
Describe the conduction system of the

heart and its relation to the formation of
the electrocardiogram (ECG).
Define the calibration of an ECG recording.
Calculate heart rate.
Calculate cardiac axis.
What is an electrocardiogram?
A recording of the changing potentials of the
electrical field imparted by the heart.
What's the point?

Fundamental part of CVS assessment.
Heart rhythm (Arrhythmias)
E.g. SR cf AF, bradycardia, tachycardia
Heart Injury
E.g. Ischaemia, infarction
Heart structure
E.g. LVH
Metabolic disorders
E.g. K
Principles of ECG I
Myocardial cells
Contraction due to Depolarisation

Relaxation due to Repolarisation
The electrical changes associated with

de- and repolarisation are recorded and
form the ECG
Principles of ECG II
Depolarisation towards
positive electrode
results in upward
deflection, away from
electrode deflection
downward
Size of deflection
reflects volume of
depolarised muscle
Conduction system of Heart

SA node
Natural pacemaker
Initiates atrial
depolarisation
AV node
Propagation of
impulse to ventricles
His-Purkinje system
Conducting tissues of
ventricles
Formation of ECG
Lead placement chest leads
Lead placement chest leads

Chest leads
(Anterior leads)
V1-V6
View heart in
horizontal plane
Lead placement - limb leads
Lead placement - limb leads

Limb Leads
I, II, III
aVL, aVF, aVR
View heart in a
vertical plane
Anatomical Relationship
Lead
Heart surface
II, III, aVF

V1-V6
I, aVL, V5-V6
Inferior
Anterior
Lateral
Technical Aspects
Technical Aspects I
ECG recorded on standard paper
Paper speed 25mm/s

Paper
1 Large square = 5mm = 0.2s
1 Small square = 1mm = 0.04s
Technical Aspects II
Electrical aspect is measured in Millivolts
Machines are calibrated
Amplitude 1mV moves stylus 1cm vertically

0.1mV = 1mm = 1 small square
Technical Aspects III

Amplitude of wave form is influenced by
Myocardial mass e.g. LVH

Thickness of intervening tissue
Distance between electrode and
myocardium
Net vector of depolarisation
Technical Aspects IV
Low amplitude
Obesity
COPD
Pericardial Fluid
High amplitude
Thin patient
Left Ventricular
Hypertrophy (LVH)
QRS Complex
Direction of deflection of ECG
Direction of electrical impulse

Towards electrode-upward deflection (Positive)
Away from electrode-downward deflection
(Negative)
When the wave of depolarisation is at right

angles to the lead Equiphasic deflection is
produced.
QRS Complex II
Normal ECG
Heart Rate
Heart Rate
Tachycardia (fast) HR>100 beats/min
Bradycardia (slow) HR<60 beats/min
1 large square = 0.2 seconds
5 large squares = 1 second
300 large squares = 1 minute
How to calculate heart rate

R-R = 2 large squares
i.e. 300 / 2 = 150/ min

R-R = 2 large squares
i.e. 300 / 2 = 150/ min
R-R = 6 large
squares
i.e. 300/6=
50/min
Heart Rhythm
Rhythm
Use a rhythm strip, Lead II commonly used
Sinus Rhythm
Normal cardiac rhythm
P wave precedes every QRS
P wave upright in leads I and II
HR 60min< RATE < 100 min
Rhythm originates in the SA node and
conducts to ventricles
Sinus Arrthymia
Common in healthy individuals
Beat-Beat variation in R-R interval with
respiration (constant PR interval)
Rate Increases with Inspiration
Vagally mediated
Increased volume of blood returns to heart

in Inspiration.
Heart Rate II
Irregular Rhythm
Heart rate calculated from rhythm strip I.e.

lead II
1 second to record 2.5cm
10 seconds to record 25cm
Count number of intervals between QRS

complexes X 6
Atrial Fibrillation-What is the

rate?
Cardiac Axis
Cardiac Axis
The average direction of spread of
the depolarisation wave through the
ventricles as measured from a zero
reference point
Cardiac Axis-Vertical Plane
Cardiac Axis II
Vertical plane = limb
leads.
Zero reference point
= lead I
Normal range
-30 to + 90
aVL-aVF
Axis above Negative

Axis below Positive
Cardiac Axis III

Normal cardiac axis 11
o clock- 5 o clock.
Right Axis Deviation

(RAD)
Axis beyond +90
Left Axis Deviation

(LAD)
Axis beyond 30
How to measure axis?

Normal
RAD
LAD
II
III
or
What is the axis?
Hexaxial approach
Choose limb lead
closest to being
equiphasic
Axis lies 90 to
equiphasic lead
Examine adjacent
leads
Why measure Axis?

Determination of axis is helpful in
diagnosis of:
Conduction defects
Broad complex tachycardias
Pre-excited conduction
PE
Break
Quiz
True/False
The following are true of the cardiac
conducting system
AV node is anterior to AV septum

Right bundle of HIS divides into 2 fascicles
Intrinsic rate of AV node higher than that of
ventricles.
AV node is under influence of vagus.
A pacemaker in right ventricle gives a similar QRS
morphology to LBBB
(F, F, T, T, T)
True/False
In a normal person during inspiration
the following statements are correct
Increased blood flow through SVC

Right ventricular systole is prolonged.
Aortic blood flow is reduced.
Heart rate is increased.
JVP is elevated.
(T, T, T, T, F)
True/False
The following are normal
Paper speed 25mm/s

1 large square = 10mm
1 small square = 1mm = 0.04s
Amplitude 1mV = 1cm
Low amplitude QRS complexes are
common
(T, F, T, T, F)
True/False
The following statements are correct
The SA node initiates atrial repolarisation

The SA node lies in the left atrium
The left bundle consists of 2 fascicles
The HIS-Purkinje system is the conducting tissues
of the ventricles
QRS complex is due to ventricular depolarisation
(F, F, T, T, T)
True/False
Heart Rate
Tachycardia = HR<100 min

1 large square = 0.2s
HR calculated using 300/squares between
R-R
In SR P wave precedes every QRS complex
Sinus arrhythmia is abnormal
(F, T, T, T, F)
True/False
Cardiac axis
To calculate cardiac axis you use the chest leads

Normal cardiac axis +30 - -90
Cardiac axis may be abnormal in broad complex
tachycardia
Axis 60 = LAD
Axis + 150 = RAD
(F, F, T, T, T)
Summary
Conduction System
SA Node-Natural pacemaker in right
atrium
AV Node-Propagation of impulse to
ventricles
His Purkinje system-Conducting tissues
to ventricles
Left bundle branch consists of 2
fascicles
Calibration
Standard paper speed = 25mm/s
1 large square = 5mm = 0.2s
Amplitude 1mV moves stylus 1cm
vertically
1 small square = 1mm = 0.04s
Heart Rate
Tachycardia HR>100 beats/min
Bradycardia HR<60 beats/min
300 large squares = 1 minute
For irregular heart rhythms, to calculate
rate count number of intervals between
QRS complexes x 6
Cardiac Axis
Calculated using limb leads (vertical
plane)
Normal axis 30 - +90
Zero reference point = lead I
LAD axis beyond 30
RAD axis beyond +90
Intervals
PR interval measured from beginning of
P wave to first deflection of QRS.
Normal PR interval 0.12-0.2s.
QRS<0.11s.
QT interval varies with rate.
Prolonged QT interval predisposes to
ventricular arrhythmias.
Nomenclature
Q Wave: Any INITIAL negative
deflection.
R Wave: Any positive deflection.
S Wave: Any negative deflection after
an R wave.
T Wave: Ventricular repolarisation.
Ventricular Hypertrophy
Sokolow and Lyon
Precordial Leads (one or more)
SV1 + RV5 or RV6
> 35mm if > 30yr of age

> 40mm if 20 30 yr
> 60mm if 16 19 yr
RV5 or RV6 > 26 mm

SV1 or SV2 > 26 mm
Limb Leads (one or more)
RI 14 mm
RaVL 12 mm
RaVR 15 mm
(Cornell Criteria- most accurate) R aVL + SV3
> 24 mm in males
> 20 mm in females
Other Enlargements
Rt atrium: P > 2.5 in II, III, aVF (p pulm) or
> 1.5 in V1
Causes: in V1 COPD, pulm HTN, thin habitus
Lt atrium: Terminal neg

P in V1 1 mm and
0.04s. Notched P 0.12s (P mitrale) in II, III
and aVF.
Inter-atrial conduction disturbance
Rt vent: R/S in V1 > 1or R/S in V5 or 6 1

RV1 7mm
Combined hypertrophy
Recommended Reading
The ECG made easy
J Hampton
ABC of electrocardiography
BMJ 2002
Any Questions?

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ECG for Beginners-Part I

Rate, Rhythm and Axis

Describe the conduction system of the

What's the point?

E.g. SR cf AF, bradycardia, tachycardia

E.g. Ischaemia, infarction

Contraction due to Depolarisation

The electrical changes associated with

Conduction system of Heart

Lead placement chest leads

Lead placement chest leads

Lead placement - limb leads

Lead placement - limb leads

II, III, aVF

Paper speed 25mm/s

Amplitude 1mV moves stylus 1cm vertically

Technical Aspects III

Myocardial mass e.g. LVH

Direction of electrical impulse

When the wave of depolarisation is at right

How to calculate heart rate

How to calculate heart rate

How to calculate heart rate

Increased volume of blood returns to heart

Heart rate calculated from rhythm strip I.e.

Count number of intervals between QRS

Atrial Fibrillation-What is the

Cardiac Axis-Vertical Plane

Axis above Negative

Cardiac Axis III

Right Axis Deviation

Axis beyond +90

Left Axis Deviation

How to measure axis?

What is the axis?

Why measure Axis?

AV node is anterior to AV septum

Increased blood flow through SVC

Paper speed 25mm/s

The SA node initiates atrial repolarisation

Tachycardia = HR<100 min

To calculate cardiac axis you use the chest leads

SV1 + RV5 or RV6

> 35mm if > 30yr of age

RV5 or RV6 > 26 mm

Limb Leads (one or more)

(Cornell Criteria- most accurate) R aVL + SV3

Causes: in V1 COPD, pulm HTN, thin habitus

Lt atrium: Terminal neg

Inter-atrial conduction disturbance

Rt vent: R/S in V1 > 1or R/S in V5 or 6 1

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