KINE 439 - Dr.

Green

Electrophysiology and ECG Basics

Rate & Axis

 Introduction to Electrocardiography (ECG, EKG)

• Electrocardiography - graphic recording of the electrical activity

(potentials) produced by the conduction system and the myocardium

of the heart during its depolarization / re-polarization cycle.

• During the late 1800's and early 1900's, Dutch physiologist Willem
Einthoven developed the early electrocardiogram. He won the Nobel
prize for its invention in 1924.

• Hubert Mann first uses the electrocardiogram to describe

electrocardiographic changes associated with a heart attack in 1920.

• The science of electrocardiography is not exact. The sensitivity and

specificity of the tool in relation to various diagnoses are relatively low

• Electrocardiograms must be viewed in the context of demographics,

health histories, and other clinical test correlates. They are especially
useful when compared across time to see how the electrical activity of
the heart has changed (perhaps as the result of some pathology).
 Cardiac
Electrophysiology
Skeletal Muscle or Neuron Action Potential
 Atrial Muscle (Nodal) Action Potential

Inward Na+ and Outward K+

Ca++ ions current
(depolarization) (repolarization)

0 3
u automaticity
(u HR)

threshold

Slow spontaneous d automaticity

Inward Na+ ions (d HR)

Automaticity - a pacemaker cell’s ability to spontaneously

depolarize, reach threshold, and propagate an AP
 Myocardium Muscle Action Potential
A c tio n P o te n tia l o f a M y o c a r d ia l C e ll
+25
O v e rs h o o t
+10 m v
1 C o r r e s p o n d in g E C G O v e r la y
0
2
-2 5

-5 0
0

A c tiv e T r a n s p o r t
-7 5 N a + o u t K + b a c k in
R e s tin g P o te n tia l
- 90 m v 4
-1 0 0 SN P
AR P R R P

K+
N a+ C a++
 Depolarization progressing from left to right

Depolarization
Sequence of a
1.
“Strip” of 5
Myocardial Cells

2.

Concept 1 3.

4.
Concept 2
 The Electrical System of the Heart

Inter- nodal Tracts

SA Node

AV Node Left Bundle

Branch

Anterior Superior Fascicle

Bundle of HIS Posterior Inferior Fascicle

Septal Depolarization Fibers

Purkinjie Fibers

Right Bundle
Branch
Conduction System
of the Heart: Inter-nodal
A Conceptual Model Tract

for Illustration Left

Bundle
Branch
AV Septal
Node Bundle Depolarization
SA of HIS Fibers
Node

James Fibers Anterior

Superior
Fascicle

Posterior
Right Bundle Inferior
of Kent Fascicle
Bundle
Branch
Generation of the
Electrocardiogram
Atrial Depolarization and the Inscription of the P-wave

SA
node

Lead II electrode:
AV 60 downward rotation
node from the horizontal 0

Delay (no electrical

0 activity) before the
beginning of ventricular
depolarization due to
90 AV node function
Ventricular Depolarization and the Inscription of the QRS complex
1 . T h e s e p t u m d e p o la r iz e s f r o m t h e
in s id e o u t a n d t h e r e s u ltin g
d e p o la r iz a t io n w a v e m o v e s
a w a y fr o m th e e le c tr o d e
r e c o r d in g L e a d II
N o te : c o m p a r e d to
th e le ft v e n tr ic le , th e
r ig h t v e n t r ic le is m u c h
s m a lle r a n d c o n tr ib u te s
little to th e o v e r a ll m a in
v e c to r o f d e p o la r iz a t io n
o L e oa d I I e l e c t r o d e
60
6 0 d o w n w a rd
r o ta tio n a n g le
fr o m th e h o r iz o n ta l 0
o

2 . T h e re s t o f th e le ft v e n tr ic le
d e p o la r iz e s c o u n t e r - c lo c k w is e
fr o m th e in s id e o u t a n d c r e a te s
th e m a in c a r d ia c v e c t o r ( la r g e a r r o w )
w h ic h is e s s e n t ia lly , t h e a lg e b r a ic
s u m o f a ll o f t h e s m a ll d e p o la r iz a t io n
v e c t o r s ( in c lu d in g t h e s m a ll
c o n t r ib u tio n f r o m t h e r ig h t v e n t r ic le )
. I n a n o r m a l h e a r t , t h is v e c t o r
is a lw a y s m o v in g d ir e c t ly
t o w a r d L e a d I I , g e n e r a t in g a
m o s tly p o s itiv e Q R S c o m p le x
Ventricular Repolarization and the Inscription of the T-wave
The ECG Complex with Interval and Segment Measurements
 ECG Paper and related Heart Rate & Voltage Computations

Memorize
These 2
 The Concept of a “Lead”

Lead II

• Right arm (RA) negative, left

arm (LL) positive, right leg (RL) is -
always the ground.

•This arrangement of electrodes

enables a "directional view"
recording of the heart's electrical
potentials as they are
sequentially activated throughout G +
the entire cardiac cycle Electrocardiograph
 The Concept of a “Lead”

Lead II -
• The directional flow of electricity
from Lead II can be viewed as
flowing from the RA toward the LL +
and passing through the heart (RA
is negative LL is positive. Also, it
is useful to imagine a camera lens
taking an "electrical picture" of the
heart with the lead as its line of G
sight
 The Concept of a “Lead”
Leads I, II, and III

• By changing the LA
arrangement of which
RA
- -
arms or legs are positive
or negative, two other
leads ( I & III ) can be
created and we have two
RA - + LA
LEAD I
more "pictures" of the
heart's electrical activity
from different angles. LEAD III +LL
Lead I: RA is neg. and
LA is pos. Lead III: LA
+
LL
LEAD II
is neg. and LL is pos.

Remember, the RL is always the ground

and never takes on a positive or negative
charge.
 The Concept of a “Lead”

RA & LA
Augmented Voltage Leads
AVR, AVL, and AVF -
LEAD AVR LEAD AVL
RA LA
By combining certain
limb leads into a central
+ +
terminal, which serves
as the negative
electrode, other leads
could be formed to "fill in
the gaps" in terms of the -
RA & RL
-
LL & LA
angles of directional
recording. These leads
required augmentation LL +
of voltage to be read LEAD AVF
and are thus labeled.
 The Concept of a “Lead”

Summary of the LEAD AVR

“Limb Leads” LEAD AVL
-150o -30o

Each of the limb

leads (I, II, III, AVR, 0o
AVL, AVF) can be LEAD I
assigned an angle
of clockwise or
counterclockwise 60o
rotation to describe 120o LEAD II
its position in the 90 o
LEAD III
frontal plane. LEAD AVF
Downward rotation
from 0 is positive
and upward rotation
from 0 is negative.
 The Concept of a “Lead”

The “Precordial Leads”

4th
intercostal
Each of the space V1 V2
V3
precordial leads is V4 V5 V6
unipolar (1 electrode
constitutes a lead)
and is designed to
view the electrical
activity of the heart
in the horizontal or V1 - 4th intercostal space - right margin of sternum
transverse plane V2 - 4th intercostal space - left margin of sternum
V3 - linear midpoint between V2 and V4
V4 - 5th intercostal space at the mid clavicular line
V5 - horizontally adjacent to V4 at anterior axillary line
V6 - horizontally adjacent to V5 at mid-axillary line
 Hexaxial Array for Axis Determination

determination of the
angle of the
HEART AXIS in the
frontal plain
 Hexaxial Array for Axis Determination – Example 1

Lead I

If lead I is mostly
positive, the
axis must lie in the
right half of
of the coordinate
system (the main
vector is moving
mostly toward the
lead’s positive
electrode)
 Hexaxial Array for Axis Determination – Example 1

Lead AVF

If lead AVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system (again, the
main vector is
moving mostly
toward the lead’s
positive electrode
 Hexaxial Array for Axis Determination – Example 1

I AVF

Combining the two

plots, we see
that the axis must
lie in the bottom
right hand quadrant
 Hexaxial Array for Axis Determination – Example 1
I AVF AVL

Once the quadrant has

been determined, find
the most equiphasic or
smallest limb lead. The
axis will lie about 90o
away from this lead.
Given that AVL is the
most equiphasic lead,
the axis here is at
approximately 60o.
 Hexaxial Array for Axis Determination – Example 1
I AVF AVL

Since QRS complex in

AVL is a slightly more
positive, the true axis
will lie a little closer to
AVL (the depolarization
vector is moving a little
more towards AVL than
away from it). A better
estimate would be
about 50o (normal axis).
 Hexaxial Array for Axis Determination – Example 2

Lead I

If lead I is mostly
negative, the
axis must lie in
the left half of
of the coordinate
system.
 Hexaxial Array for Axis Determination – Example 2

Lead AVF

If lead AVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system
 Hexaxial Array for Axis Determination – Example 2

I AVF

Combining the two

plots, we see
that the axis must
lie in the bottom
left hand quadrant
(Right Axis
Deviation)
 Hexaxial Array for Axis Determination – Example 2

I AVF II

Once the quadrant

has been
determined, find the
most equiphasic or
smallest limb lead.
The axis will lie
about 90o away from
this lead. Given that
II is the most
equiphasic lead, the
axis here is at
approximately 150o.
 Hexaxial Array for Axis Determination – Example 2

I AVF II

Since the QRS in II

is a slightly more
negative, the true
axis will lie a little
farther away from
lead II than just 90o
(the depolarization
vector is moving a
little more away from
lead II than toward
it). A better estimate
would be 160o.
Precise Axis
Calculation
Precise calculation
of the axis can be
done using the
coordinate system
to plot net voltages
of perpendicular
leads, drawing a Net voltage = 12
resultant rectangle, Since Lead III is
then connecting the most

Net voltage = 7
the origin of the equiphasic lead
coordinate system and it is slightly
with the opposite more positive
corner of the than negative,
rectangle. A this axis could be
protractor can then estimated at
be used to about 40o.
measure the
deflection from 0.