ECG: Standard Limb Leads

R-R: heart rate

P-Q (R): AV conduction time
T-Q: Ventricular diastole
Q-T: Ventricular systole

Q S

P Wave: Atrial depolarisation

QRS Complex: Ventricular Depolarisation (phase 0)
T Wave: Ventricular Repolarisation
Arrhythmias: Heart Beat Originating from the Ventricle
SA AV
node node Internodal
Beat Originates from SA or AV Node Pathways
QRS Complex: normal, narrow
Bundle
of His

Purkinje
Beat Originates from the Ventricle Fibres

QRS Complex: Abnormal, wide

Bundle
Branches
 Atrial and Ventricular Ectopic Beats
Ectopic Beat: Arises from electrical activity originating at a site other
than the sinoatrial (SA) node.

An ectopic beat usually manifests as a

premature atrial or ventricular contraction.
 Arrhythmias: Premature and Late Beats
R

The rhythm is generally normal but there are occasional P T

early or late beats.
Q
Premature atrial contraction (normal QRS) S

Premature ventricular contraction (Abnormal QRS)

 Arrhythmias: Impaired Conductance
First Degree Heart Block

R
First Degree Heart Block
P T

Q
S

Normal Rhythm

• Slow conduction through the AV node.

• Prolonged PR interval (> 0.2 sec).
• No treatment; highly-trained athletes
• Enhanced vagal tone; AV node disease; electrolyte imbalance
 Arrhythmias: Impaired Conductance
Second Degree Heart Block

Missing QRS

• Impulses are intermittently blocked at the AV junction.

• Not all P waves are followed by a QRS complex.

• Progressive increase in delay until a beat is skipped (Type I).
• 2-4 P waves for every QRS complex (Type II)
 Arrhythmias: Impaired Conductance
Third Degree Heart Block

• Complete lack of conduction through the AV node

•“Escape QRS Complex”: Generated in the ventricle

 Narrow QRS complex (stable heart)
Generated near the Bundle of His
 Wide QRS complex (unstable heart)
Generated below the Bundle of His

• heart attack; increased vagal tone; drug intoxication

• pacemaker required
 Heart Block
PR interval

PR interval
 Arrhythmias: Impaired Conductance
Branch Bundle Block

• Impulses originate in the SA node and spread normally through the atria and
AV junction, however, the conduction through the right (R) or left (L)
branch bundles is blocked.

• In LBBB the left ventricle is activated late; in RBBB the right ventricle
is activated late
left bundle
branch

right bundle
branch
 Arrhythmias: Flutter and Fibrillation
• Very rapid rates of electrical excitation and contraction in either the atria or the ventricles
can produce flutter or fibrillation.

Atrial Flutter

Rapid 200-300 per minute;

contractions are coordinated.

• Heart rate is so fast that the isoelectric interval between the end of the
T wave and the beginning of the P wave disappears
• The AV-node and, thereafter, the ventricles are
generally activated by every second
or every third atrial impulse.
SA node
mitral valve disease, pulmonary embolism, AV node
hypoxia, electrolyte disturbances and
hypercalcaemia
 Arrhythmias: Flutter and Fibrillation
Atrial Fibrillation
•Extremely chaotic electrical
activity in the atria.

valve diseases,
pericarditis,
lung disease and
congenital heart defects
 Arrhythmias: Fibrillation
Ventricular Fibrillation
• Caused by continuous recycling of electrical activity
through the myocardium.

• Recycling is normally prevented due to the

myocardium refractory period (post-contraction).

• However, if some cells emerge from their refractory period

before others, electrical waves can be continuously regenerated
and conducted leading to uncoordinated contraction
and impotent pumping.
 Ventricular Fibrillation (Re-entry circuits)
unidirectional
block

conduction both ways conduction one way only

dead cells

normal cells
 Arrhythmias: Flutter and Fibrillation
Ventricular Fibrillation
• Ventricular fibrillation leads to death within a few minutes.
• Fibrillation can be stopped (sometimes) by a strong electrical shock
delivered to the chest.

drug toxicity, electrocution,

drowning and myocardial
infarction.
 The Electrical Axis of the Heart
• The mean electrical axis is the average of all the instantaneous mean electrical
vectors occurring sequentially during depolarization of the ventricles.
Left
4

3 R
1
2
3
Lead II
Right 2

Q
1 S
4
1. Conduction down the branch bundles → interventricular septum depolarises
from left to right (Q wave; negative; away from the positive lead II electrode).
2. 20 msec later: Depolarisation towards the apex (vector 2)
3. 20 msec later: Depolarisation towards the left arm (vector 3)
4. S Wave (vector 4)
 Diagnostic Use of the Heart’s Electrical Axis
Left
Deviation to the Right

Increased Right Ventricular Mass (Ventricular hypertrophy)

Right

Chronic obstructive lung disease

Pulmonary embolism
Congenital heart defects
Severe pulmonary hypertension
 Diagnostic Use of the Heart’s Electrical Axis
Deviation to the Left

Increased Left Ventricular Mass (left ventricular hypertrophy)

Hypertension
Aortic stenosis
Ischemic heart disease
 Calculating the Mean Electrical Axis

1. Look at the lead I ECG. Calculate the isoelectric line to R distance. This equals “a”
2. Look at the lead I ECG. Calculate the isoelectric line to S distance. This equals “b”
3. Add “a” plus “b”. Note that “b” is a negative value.
4. Do the same for the lead II and II ECG traces to find “c”, “d”, “e” and “f”.
5. Calculate “c + d” and “e + f”
6. Draw an equilateral triangle.
7. Starting at the centre of each line (which represent leads I, II and II) measure the distance
represented by “a + b”, “c + d” and “e + f” (right is positive).
8. Draw a perpendicular line from the end of these vectors into the middle of the triangle.
9. Determine the centre of the triangle.
10. Draw a line from the centre of the triangle to the point at which the perpendicular
lines (from the end of a + b, c + d and e + f meet).
11. The line from the centre of the triangle the meeting point of these lines represents
the mean electrical axis of the heart.

Follow these instructions while looking

at the following slide.
 Lead I Calculating the Mean Electrical Axis
2 mV
R I
a a+b
b
Q
S
- 2 mV
II
Lead II
2 mV e+f
c+d
R
c Lead III
2 mV III
d R
Q
S e
- 2 mV f
Q
S
- 2 mV
Use the following information and diagrams to calculate the mean electrical
axis of the heart. Each division on the leads equals 1.

Magnitude of the QRS complex in lead I = 2

Magnitude of the QRS complex in lead II = 5
Magnitude of the QRS complex in lead III = 3
270

225 315
a) Approximately 33°
b) Approximately 43°
180 0
c) Approximately 67°
d) Approximately 90°
135 45
e) Approximately 115°
90

270
225 315

180 0

135 45
90
Use the following information and diagrams to calculate the mean electrical
axis of the heart. Each division on the leads equals 1.

Magnitude of the QRS complex in lead I = 2

Magnitude of the QRS complex in lead II = 5
Magnitude of the QRS complex in lead III = 3
270

225 315
a) Approximately 33°
b) Approximately 43°
180 0
c) Approximately 67°
d) Approximately 90°
135 45
e) Approximately 115°
90

270
225 315

Step 1: Plot the QRS complex 180 0

magnitude on the appropriate

135 45
lead.
90
Use the following information and diagrams to calculate the mean electrical
axis of the heart. Each division on the leads equals 1.

Magnitude of the QRS complex in lead I = 2

Magnitude of the QRS complex in lead II = 5
Magnitude of the QRS complex in lead III = 3
270

225 315
a) Approximately 33°
b) Approximately 43°
180 0
c) Approximately 67°
d) Approximately 90°
135 45
e) Approximately 115°
90

270
225 315

Step 2: Draw perpendicular lines

from the end of the drawn vector 180 0

into the triangle. They should

135 45
all meet.
90
Use the following information and diagrams to calculate the mean electrical
axis of the heart. Each division on the leads equals 1.

Magnitude of the QRS complex in lead I = 2

Magnitude of the QRS complex in lead II = 5
Magnitude of the QRS complex in lead III = 3
270

225 315
a) Approximately 33°
b) Approximately 43°
180 0
c) Approximately 67°
d) Approximately 90°
135 45
e) Approximately 115°
90

270
225 315

Step 3: Draw perpendicular lines

180 0
from the middle of each lead into
the triangle. They will meet at the 135 45
centre. 90
Use the following information and diagrams to calculate the mean electrical
axis of the heart. Each division on the leads equals 1.

Magnitude of the QRS complex in lead I = 2

Magnitude of the QRS complex in lead II = 5
Magnitude of the QRS complex in lead III = 3
270

225 315
a) Approximately 33°
b) Approximately 43°
180 0
c) Approximately 67°
d) Approximately 90°
135 45
e) Approximately 115°
90

270
225 315
Step 4: Draw a line from the
centre of the triangle to the 180 0
point at which the three lines
perpendicular to the ends of the 135 45
vectors meet. This is the axis. 90
The Cardiac Cycle
 The Stages of the Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Isovolumetric: constant volume

 1 2 3 4
AV Valves
Semilunar Valves

Aortic Pressure

Overview of
Ventricular
the Pressure Pressure
and Volume
Atrial Pressure
Changes in the
Cardiac Cycle
(Details to come)

Ventricular
Volume
When the ventricles Right Atria to Right Ventricle
contract; the AV
valves close.
to the lungs
from the systemic
circulation Pulmonary Arteries

from the lungs

LA
RA RA: right atria
RV: right ventricle
Tricuspid (AV) LA: left atria
Valve LV
LV: left ventricle
RV

Right Left
aorta to the systemic circulation
Pressure in RA > Pressure in RV: Tricuspid Valve Open

Pressure in RA < Pressure in RV: Tricuspid Valve Closed

When the ventricles Right Atria to Right Ventricle
contract; the AV
valves close. Pulmonary Artery Pulmonary Artery

RA RA

RV
RV

Ventricles Relaxed Ventricles Contracting

Pressure in RA > Pressure in RV: Tricuspid Valve Open

Pressure in RA < Pressure in RV: Tricuspid Valve Closed

When the ventricles Left Atria to Left Ventricle
contract; the AV
valves close.
to the lungs

Pulmonary Arteries

from the lungs

LA
RA: right atria RA
RV: right ventricle Bicuspid (AV)
LA: left atria
Valve
LV: left ventricle LV
RV

Right Left
aorta to the systemic circulation
Pressure in LA > Pressure in LV: Bicuspid Valve Open

Pressure in LA < Pressure in LV: Bicuspid Valve Closed

Ventricular contraction Left Ventricle to Aorta
leads to the opening of the
semilunar valves.
to the lungs

Pulmonary Arteries

from the lungs

LA
RA
Semilunar
valve
LV
RV
Right
Left
aorta to the systemic circulation
Pressure in Aorta > Pressure in LV: Semilunar Valve Closed

Pressure in Aorta < Pressure in LV: Semilunar Valve Open

Ventricular contraction Right Ventricle to Pulmonary Artery
leads to the opening of the
semilunar valves.
to the lungs
from the systemic
circulation Pulmonary Arteries
Semilunar from the lungs
valve LA
RA RA: right atria
RV: right ventricle
LA: left atria
LV
LV: left ventricle
RV

Right Left
aorta to the systemic circulation
Pressure in Pulmonary Artery > Pressure in RV: Semilunar Valve Closed

Pressure in Pulmonary Artery < Pressure in RV: Semilunar Valve Open

 Pulmonary
Valve Diseases Arteries
Aorta

• Stenosis: Valve doesn’t open fully

Semilunar
Extra workload for the heart. LA valve
RA
Normal Open Valve LV
Left
Right RV

Valve that
doesn’t open
wide enough
 Pulmonary
Valve Diseases Arteries
Aorta
• Regurgitation (Insufficiency):
Valve doesn’t close properly Semilunar
(blood leaks backwards) LA valve
RA
Reduced blood flow to organs. LV
Left
Right RV

Normal Closed Valve

Leaky Valve
 Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Isovolumetric: constant volume

 • Pressure (ventricle, atria AV Valves
and aorta) Semilunar Valves
• Volume Aortic Pressure
• Valves (open/closed)
Ventricular
Pressure
Semilunar Valves Atrial
Pressure

aorta
PA

Ventricular
Left volume
Right
• Systole: contraction
• Diastole: relaxation
AV Valves
Late Diastole (1) 1 2 •3AV: atrioventricular
4
(atria to ventricles)
AV Valves
Semilunar Valves • semilunar valves:
(ventricles to blood
vessels)

Semilunar Valves
Aortic Pressure
passive filling

aorta
PA passive Atrial Pressure
filling
Ventricular Pressure

Ventricular Volume
passive filling

Atria contraction

AV Valves Passive filling

Late Diastole (1) 1 2 •3AV: atrioventricular
4
(atria to ventricles)
AV Valves
Semilunar Valves • semilunar valves:
(ventricles to blood
Passive Filling vessels)

PA
Aortic Pressure

Atrial Pressure
Atrial Contraction Ventricular Pressure

PA Ventricular Volume

Atria contraction
Left
Passive filling
Right
 Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Isovolumetric: constant volume

Systole (2) 1 2 3 • AV: atrioventricular
4
(atria to ventricles)
AV Valves
Semilunar Valves • semilunar valves:
(ventricles to blood
vessels)
Aortic Pressure
Semilunar Valves

aorta Ventricular Pressure

PA

Atrial Pressure

Left Ventricular Volume

Right

AV Valves
• Isovolumetric contraction
Systole (2) 1 2 3 • AV: atrioventricular
4
(atria to ventricles)
AV Valves
Semilunar Valves • semilunar valves:
(ventricles to blood
vessels)
P (aorta) > P (ventricle):
Aortic Pressure
Aortic (semilunar) valve close

PA Ventricular Pressure

Atrial Pressure

Ventricular Volume

P (ventricle) > P (atria):

AV valves close
• Isovolumetric contraction
 Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Isovolumetric: constant volume

 • AV: atrioventricular
Systole (3) 1 2 3 (atria to ventricles)
AV Valves • semilunar valves:
(ventricles to blood
Semilunar Valves vessels)
Ventricular
Pressure
Semilunar Valves Aortic Pressure

aorta
PA

Atrial Pressure

Left
Right

AV Valves Ventricular
Volume
Systole (3) 1 2 3 4 • (atria
AV: atrioventricular
to ventricles)
AV Valves • semilunar valves:
(ventricles to blood
Semilunar Valves vessels)
Ventricular
P (aorta) < P (ventricle): Pressure
Aortic (semilunar) valve open Aortic Pressure

PA

Atrial Pressure
Left

Right

Ventricular
Volume
 Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Isovolumetric: constant volume

 • AV: atrioventricular
Early Diastole (4) 1 2 3 4 (atria to ventricles)
AV Valves • semilunar valves:
• Isovolumetric Semilunar Valves
(ventricles to blood
relaxation vessels)

Aortic Pressure
Semilunar Valves

Ventricular
aorta Pressure
• tension
PA

Atrial Pressure

Left
Right

AV Valves Ventricular
Volume
 • AV: atrioventricular
Early Diastole (4) 1 2 3 4 (atria to ventricles)
AV Valves • semilunar valves:
• Isovolumetric Semilunar Valves
(ventricles to blood
relaxation vessels)

Aortic Pressure

PA Ventricular
Pressure

Left
Atrial Pressure*

Right

Ventricular
*, Changes in atrial pressure Volume
are of little significance.
 Late Diastole (1) 1 2 3 4
AV Valves
Semilunar Valves
Passive Filling Aortic Pressure

PA

Ventricular
Pressure
Atrial Pressure
Atrial Contraction

PA

Ventricular
Left
Right Volume
 Cardiac Cycle
2 3
Isovolumetric Ventricular
1 Ejection
Contraction 4
Atrial
Isovolumetric
Contraction
Relaxation

Ventricular
Filling

Diastole (relaxation): 65% of the cycle Filling Time

Systole (contraction): 35% of the cycle