ECG

Electrocardiograph

Yang HaiBo MD
• Department of cardiology,
• 1st affiliated hospital of ZZU
心电图之父
Einthoven
Willem Einthoven
(1860~1927), 出生印度
尼西亚， 荷兰 Leiden 大学
生理学和组织学教授。
发展了弦线式电流计使
心电图记录更为精确，创立
的心电图波形名称
（ P 、 Q 、 R 、 S 、 T ）和
双极肢体导联系统一直沿用
至今，发表了多篇重要的心
电图论文。
1924 年获得诺贝尔医学
奖。
• Einthoven applied the string galvanometer to the
recording of the cardiac electrical activity in 1903 .
• He also coined the term elektrokardiogramm in
German (the dominant language at the time for
scientific publications) and labeled the recorded
waveforms P, Q, R, S, T, and U.
• Einthoven also described numerous abnormal
findings and created the bipolar limb lead system
known as Einthoven’s triangle.
 The Heart
• The heart consists of four
chambers
– The right atrium and right
ventricle: responsible for
delivery of deoxygenated
blood to lungs
– The left atrium and left
ventricle: responsible for
delivery of oxygenated
blood to the body
The mechanical activity of the
heart
There are two phases of the cardiac
cycle
• Systole: The ventricles are full of blood
and begin to contract. The mitral and
tricuspid valves close (between atria
and ventricles). Blood is ejected
through the pulmonic and aortic valves.
• Diastole: Blood flows into the atria and
through the open mitral and tricuspid
valves into the ventricles.
excitation-contraction
coupling
心脏的基本活动为电和机械活动，在每一个
心动周期中

电活动 机械活动
(Electrical activity ) (mechanical activity)

兴奋 Ca++ 收缩
耦联
The electrical activity of
the heart
• When the heart muscle contracts
there are electrical changes called
depolarisation - followed by
repolarisation as the myocardium
recovers
• The heart is a single muscle made up of many
interconnecting myocardial cells - a syncytium
• When a part of the heart is stimulated a wave of
depolarisation is propagated from that point over
the entire myocardium.
• The depolarisation is accompanied by contraction
of the myocardial cells, and thus systole
 Electrocardiogram (ECG)
• The ECG records the electrical signal of
the heart as the muscle cells depolarize
and repolarize at the body surface.
• Normally, the SA Node generates the initial
electrical impulse and begins the cascade
of events that results in a heart beat.
• Recall that cells resting have a negative
charge with respect to exterior and
depolarization consists of positive ions
rushing into the cell
Schematic representation of the factors
resulting in recording the ECG

The major paths leading to

the ECG are marked by
solid arrows, while factors
influencing or perturbing
this path are shown with
dotted arrows.
• First, an extracellular cardiac electrical field is
generated by ion fluxes across cell membranes and
between adjacent cells. These ion currents are
synchronized by cardiac activation and recovery
sequences to generate a cardiac electrical field in and
around the heart that varies with time during the
cardiac cycle.
• This electrical field passes through numerous other
structures, including the lungs, blood, and skeletal
muscle, before reaching the body surface. These
structures--known as transmission factors--differ in their
electrical properties and perturb the cardiac electrical
field as it passes through them.
• The potentials reaching the skin are then detected by
electrodes placed in specific locations on the extremities
and torso and configured to produce leads.
• The outputs of these leads are amplified, filtered, and
displayed by a variety of electronic devices to construct
an ECG recording.
• Finally, diagnostic criteria are applied to these
recordings to produce an interpretation. The criteria
have statistical characteristics that determine the
clinical utility of the findings.

Each of these steps influences the final product--the

clinical ECG.
How does it works…
• The heart is a muscle with well-
coordinated electrical activity, so the
electrical activity within the heart can be
easily detected from outside of the
body.

• After the appropriate leads are attached

to the body, a heated stylus moves
upward with positive voltage and
downward for negative voltage.

• On the moving heat-sensitive paper,

voltage is traced out.

• The test takes about five minutes,and it

is fairly painless.
心电图记录原理

electrode

心电图
0.04sec
 ECG clinical
application
diagnose cardiac problems
• Major
myocardial infarction
arrhythmia
• Others
atrium or ventricle hypertrophy
drug effects
electrolyte abnormality
………..
ECG Diagnosis
FUNDAMENTAL
PRINCIPLES
the resting potential
• Myocytes maintain a potential difference
between the interior and the exterior of the
cell of approximately –90 mV. This electrical
transmembrane gradient depends on the
chemical transmembrane gradient, which
exists because the concentration of
negative ions is higher inside the cell than
outside. Such uneven distribution of ions is
sustained by a sodium pump housed in the
cell membrane .
Depolarization and
repolarization
• Electrical stimuli change the resting
potential inside the cell from –90 mV to
approximately +30 mV (depolarization),
and the electrical activity recorded during
this process is the action potential.
Depolarization initiates the propagation of
the impulse along both the interior and the
exterior of the “polarized” membrane.
• Electrical systole continues until the positively
charged ions exit the cell, which causes
repolarization (i.e., restitution of membrane
polarity).
• When the cells are at rest, they have a
negative transmembrane voltage –
surrounding media is positive
• When the cells depolarize, they switch to a
positive transmembrane voltage –
surrounding media becomes negative
• When the cells repolarize, they restitution
of membrane polarity ,switch to a negative
transmembrane voltage – surrounding
media becomes positive
Cell Depolarization
• Flow of sodium ions into cell during
activation

Depol Repol. Restoration of ionic balance

Rules of ECG
• Wave of depolarization traveling towards a
positive electrode causes an upward
deflection on the ECG
• Wave of depolarization traveling away
from a positive electrode causes a
downward deflection on the ECG
•Wave of Repolarization traveling away from
a positive electrode causes an upward
deflection on the ECG
• Wave of repolarization traveling towards a
positive electrode causes. . . . . . . ?
 Depol. toward positive electrode Repol. toward positive electrode
Positive Signal Negative Signal

Depol. away from positive electrode Repol. Away from positive electrode
Negative Signal Positive Signal
Laws of Ventricular
Depolarization &
Repolarization
• Ventricular depolarization begins in the
Ventricular depolarization begins in the
endocardium and ends in the epicardium
, following an inside-out course.
• Ventricular repolarization, however,
follows an inverted pattern. The process
begins in the epicardium and ends in the
endocardium.
Therefore the polarity of the
repolarization waveform is the same as
that of depolarization
 Laws of VentricularDepolarization &
Repolarization
Depolarization
Repolarization
Propagating Activation
Wavefront
Cardiac conduction
system
 ECG Signal
Heart behaves as a syncytium: a
•
propagating wave that once
initiated continues to propagate
uniformly into the region that is still
at rest.
• The depolarization wavefront
defines a dividing line between
activated and resting cells.
• Elsewhere, the signal is zero
• Will propagate along conduction
paths – sinus node – AV node –
bundle branches – Purkinjie fibers
Cardiac impulse -Sequence
• SA node initiates beat
– R atrium→L atrium rapid
• AV node and Bundle of His
– from atria through fibrous, non-conducting, AV ring
→ interventricular septum slight delay
• R and L bundles in interventricular septum
– via Purkinke fibres/system branching throughout
ventricular myocardium → ‘simultaneous’
contraction of ventricles rapid
ECG waveform
Electrocardiograph
Equipment
Electrocardiographs are calibrated to give a
deflection of 10 mm per millivolt (this
calibration is usually seen at the beginning
or end of the ECG); thus, 1 mm equals 0.1
mV.

Electrocardiographic paper is graph paper

divided in little squares of 1 mm each and
larger squares of 5 mm each. The speed of
the paper is standardized to 25 mm per
second.
• ECG paper divided into small 1 mm, and large 5mm
squares
1 large square = 5 small squares

• ECG paper runs at 25 mm per sec

• 1 small square = 1/25 = 0.04 sec
• 1 large square = 1/5 = 0.2 sec
• 5 large squares = 1 sec
• 300 large squares = 1 min

• Thus, precise measurements can be made of ECG intervals and the HR

0.04sec
ECG waveform
• The origin of the cardiac impulse in the
sinus node is electrocardiographically
mute;
• The initial electrical wave of each cardiac
cycle is the P wave, which represents the
spread of the activation through the atria.
• The QRS complex is the recording of the
ventricular activation and it may appear as
one (monophasic), two (diphasic), or three
(triphasic) individual waveforms.
• The T wave represents ventricular
recovery and is sometimes followed by a
small upright deflection called the U wave.
• The ST segment is the interval between the
end of ventricular activation and the
beginning of ventricular recovery.
• The QT interval measures the time from the
onset of ventricular activation to the end of
ventricular recovery. This term is used
whether the QRS complex begins with a Q
or an R wave.
 ECG waves
waves – Deflections
from isoelectric base
line
• P – atrial
depolarization
• QRS complex –
ventricular
depolarization
• T – ventricular
repolarization
• U_
ECG intervals
• PR interval: time interval
from onset of atrial
depolarization (P wave)

• QT interval: duration of
ventricular
depolarization and
repolarization

• QRS duration: duration

of ventricular muscle
depolarization
QRS waveform
nomenclature
• Q wave - first downward deflection
• R wave - First upward deflection
• S wave -downward deflection following R

Low-amplitude or narrow waves are denoted with

lowercase letters (e.g., q, r, s wave) and taller, wider
waves with capital letters (e.g., Q,R,S wave).
QRS waveform
nomenclature

R r qR qRs Qrs QS

Qr Rs rS qs rSr’ rSR’
The 12 ECG leads
Types of ECG lead
There are two basic types of ECG leads:
• Bipolar leads (standard limb leads) utilize a
single positive and a single negative
electrode between which electrical
potentials are measured. 
• Unipolar leads (augmented leads and chest
leads) have a single positive recording
electrode and utilize a combination of the
other electrodes to serve as a composite
negative electrode.
　 　　

1906 年 Einthoven 创建了标准双极肢体导联 (Bipolar Limb

Lead) , 导联名称： I 、 II 、 III 导联

1932 年 Lewis- Wilson 共同创立了单极胸前导联 (Unipolar

Precordial Lead) ，简称胸导，共有 6 个（ V1~V6 ）

1942 年 Goldberger 创用单极加压肢体导联 (Augmented

Unipolar Limb Lead) 导联名称： aVR 、 aVL 、 aVF
Bipolar limb lead
frontal plane
difference potentials between 2 limbs
Augmented unipolar limb lead
frontal plane
difference potentials between limb
exploring electrode and central terminal
UnipolarPrecordial lead
horizontal plane
difference potentials between precordial
exploring electrode and central terminal
Central terminal
precordial leads
connecting three limbs (R L F)
electrodes together through 5000-ohm
resistor , the potentials is zero .

Incomplete Central terminal

augmented limb leads
connecting the other two limbs
electrodes together through 5000-ohm
resistor excluding the exploring
electrode
 12 Leads System

Lead Ⅰ Ⅱ Ⅲ

Lead aVr aVl aVf

Lead V1 ~ V6
Bipolar Limb Lead
Augmented Unipolar Limb
Lead
Precordial Leads
PLACEMENT OF PRECORDIAL LEAD
ELECTRODES
• V1-Fourth intercostal space, right sternal
border
• V2-Fourth intercostal space, left sternal
border
• V3-Equidistant between V2 and V4
• V4-Fifth intercostal space, at the
midclavicular line
• V5-Anterior axillary line, at the level of
lead V4
• V6-Midaxillary line, at the level of lead V4
• V7-Posterior axillary line in the fifth intercostal
space
• V8-Midscapular line
• V9-Left paraspinal border
• V3R-Equidistant between V1 and V4R
• V4R-Right midclavicular line, fifth intercostal
space
• V5R-Right anterior axillary line in the same
horizontal plane as V4R
• V6R-Right midaxillary line in the same horizontal
plane as V4R
 Clinical Significance
• Lead Ⅱ Ⅲ aVf inferior wall
• Lead Ⅰ aVl high lateral wall
• Lead V 1 ~ V 2 septum
• Lead V 3 ~ V 4 anterior wall
• Lead V 5 ~ V 6 lateral wall
• Lead aVr V3r~5r right ventricle
• Lead V7 ~ V 9 posterior wall
Electrical vectors and how
they apply to the heart
• The inferior leads (leads II, III and aVF) look at
electrical activity from the vantage point of the
inferior region (wall) of the heart. The lateral leads
(I, aVL, V5 and V6) look at the electrical activity
from the vantage point of the lateral wall of the
heart. The anterior leads, V1 through V6, and
represent the anterior wall of the heart. aVR is
rarely used for diagnostic information, but
indicates if the ECG leads were placed correctly
on the patient.

• The inferior leads record events from the apex of

the left ventricle. The lateral and anterior leads
record events from the left wall and front walls of
the left ventricle, respectively. The right ventricle
has very little muscle mass. It leaves only a small
imprint on the ECG, making it more difficult to
diagnose than changes in the right ventricle.
seismograph