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

How to calculate heart rate

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

How to calculate heart rate

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?