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Electrocardiography
FromWikipedia,thefreeencyclopedia

Electrocardiography(ECGorEKG[a])istheprocessof
recordingtheelectricalactivityoftheheartoveraperiodoftime Electrocardiography
usingelectrodesplacedontheskin.Theseelectrodesdetectthe Intervention
tinyelectricalchangesontheskinthatarisefromtheheart
muscle'selectrophysiologicpatternofdepolarizingand
repolarizingduringeachheartbeat.Itisaverycommonly
performedcardiologytest.

Inaconventional12leadECG,10electrodesareplacedonthe
patient'slimbsandonthesurfaceofthechest.Theoverall
magnitudeoftheheart'selectricalpotentialisthenmeasured
from12differentangles("leads")andisrecordedoveraperiod
oftime(usually10seconds).Inthisway,theoverallmagnitude
anddirectionoftheheart'selectricaldepolarizationiscaptured
ateachmomentthroughoutthecardiaccycle.[4]Thegraphof
voltageversustimeproducedbythisnoninvasivemedical
procedureisreferredtoasanelectrocardiogram.

Duringeachheartbeat,ahealthyhearthasanorderly ECGofaheartinnormalsinusrhythm.
progressionofdepolarizationthatstartswithpacemakercellsin ICD9CM 89.52
thesinoatrialnode,spreadsoutthroughtheatrium,passes
throughtheatrioventricularnodedownintothebundleofHis MeSH D004562
andintothePurkinjefibers,spreadingdownandtotheleft MedlinePlus 003868
throughouttheventricles.Thisorderlypatternofdepolarization
givesrisetothecharacteristicECGtracing.Tothetrainedclinician,anECGconveysalargeamountof
informationaboutthestructureoftheheartandthefunctionofitselectricalconductionsystem.[5]Amongother
things,anECGcanbeusedtomeasuretherateandrhythmofheartbeats,thesizeandpositionoftheheart
chambers,thepresenceofanydamagetotheheart'smusclecellsorconductionsystem,theeffectsofcardiac
drugs,andthefunctionofimplantedpacemakers.[6]

Contents
1 History
2 Medicaluses
3 Electrocardiographs
4 Electrodesandleads
4.1 Limbleads
4.2 Augmentedlimbleads
4.3 Precordialleads
4.4 Specializedleads
4.5 LeadlocationsonanECGreport
4.6 Contiguityofleads
5 Electrophysiology
6 Interpretation
6.1 Theory

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6.2 Electrocardiogramgrid
6.3 Rateandrhythm
6.4 Axis
6.5 Amplitudesandintervals
6.6 Ischemiaandinfarction
6.7 Artifacts
7 Diagnosis
8 Seealso
9 Notes
10 References
11 Externallinks

History
TheetymologyofthewordisderivedfromtheGreekelectro,becauseitis
relatedtoelectricalactivity,kardio,Greekforheart,andgraph,aGreek
rootmeaning"towrite".

AlexanderMuirheadisreportedtohaveattachedwirestoafeverish
patient'swristtoobtainarecordofthepatient'sheartbeatin1872atSt
Bartholomew'sHospital.[7]AnotherearlypioneerwasAugustusWaller,of
StMary'sHospitalinLondon.[8]Hiselectrocardiographmachineconsisted
ofaLippmanncapillaryelectrometerfixedtoaprojector.Thetracefrom
theheartbeatwasprojectedontoaphotographicplatethatwasitselffixed
toatoytrain.Thisallowedaheartbeattoberecordedinrealtime. AnearlycommercialECGdevice
(1911)
AninitialbreakthroughcamewhenWillemEinthoven,workinginLeiden,
theNetherlands,usedthestringgalvanometer(thefirstpractical
electrocardiograph)heinventedin1901.[9]Thisdevicewasmuchmore
sensitivethanboththecapillaryelectrometerWallerusedandthestring
galvanometerthathadbeeninventedseparatelyin1897bytheFrench Electrocardiography(1957)
[10]
engineerClmentAder. Einthovenhadpreviously,in1895,assignedthe
lettersP,Q,R,S,andTtothedeflectionsinthetheoreticalwaveformhecreatedusingequationswhichcorrected
theactualwaveformobtainedbythecapillaryelectrometertocompensatefortheimprecisionofthatinstrument.
UsinglettersdifferentfromA,B,C,andD(thelettersusedforthecapillaryelectrometer'swaveform)facilitated
comparisonwhentheuncorrectedandcorrectedlinesweredrawnonthesamegraph.[11]Einthovenprobablychose
theinitialletterPtofollowtheexamplesetbyDescartesingeometry.[11]Whenamoreprecisewaveformwas
obtainedusingthestringgalvanometer,whichmatchedthecorrectedcapillaryelectrometerwaveform,he
continuedtousethelettersP,Q,R,S,andT,[11]andtheselettersarestillinusetoday.Einthovenalsodescribedthe
electrocardiographicfeaturesofanumberofcardiovasculardisorders.In1924,hewasawardedtheNobelPrizein
Medicineforhisdiscovery.[12]

In1937,TaroTakemiinventedthefirstportableelectrocardiographmachine.[13]

Thoughthebasicprinciplesofthateraarestillinusetoday,manyadvancesinelectrocardiographyhavebeen
madeovertheyears.Instrumentationhasevolvedfromacumbersomelaboratoryapparatustocompactelectronic
systemsthatoftenincludecomputerizedinterpretationoftheelectrocardiogram.[14]

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Medicaluses
Theoverallgoalofperformingelectrocardiographyisto
obtaininformationaboutthestructureandfunctionofthe
heart.Medicalusesforthisinformationarevariedand
generallyrelatetohavinganeedforknowledgeofthe
structureand/orfunction.Someindicationsforperforming
electrocardiographyinclude:

Suspectedmyocardialinfarction(heartattack)or
newchestpain A12leadECGofa26yearoldmalewithan
Suspectedpulmonaryembolismornewshortnessof incompleteRBBB
breath
Athirdheartsound,fourthheartsound,acardiac
murmur[15]orotherfindingstosuggeststructuralheartdisease
Perceivedcardiacdysrhythmias[15]eitherbypulseorpalpitations
Monitoringofknowncardiacdysrhythmias
Faintingorcollapse[15]
Seizures[15]
Monitoringtheeffectsofaheartmedication(e.g.druginducedQTprolongation)
Assessingseverityofelectrolyteabnormalities,suchashyperkalemia
Hypertrophiccardiomyopathyscreeninginadolescentsaspartofasportsphysicaloutofconcernforsudden
cardiacdeath(variesbycountry)
Perioperativemonitoringinwhichanyformofanesthesiaisinvolved(e.g.monitoredanesthesiacare,
generalanesthesia)typicallybothintraoperativeandpostoperative
Asapartofapreoperativeassessmentsometimebeforeasurgicalprocedure(especiallyforthosewith
knowncardiovasculardiseaseorwhoareundergoinginvasiveorcardiac,vascularorpulmonaryprocedures,
orwhowillreceivegeneralanesthesia)
Cardiacstresstesting
Computedtomographyangiography(CTA)andMagneticresonanceangiography(MRA)oftheheart(ECG
isusedto"gate"thescanningsothattheanatomicalpositionoftheheartissteady)
Biotelemetryofpatientsforanyoftheabovereasonsandsuchmonitoringcanincludeinternalandexternal
defibrillatorsandpacemakers

TheUnitedStatesPreventiveServicesTaskForcedoesnotrecommendelectrocardiographyforroutinescreening
procedureinpatientswithoutsymptomsandthoseatlowriskforcoronaryheartdisease.[16][17]Thisisbecausean
ECGmayfalselyindicatetheexistenceofaproblem,leadingtomisdiagnosis,therecommendationofinvasive
procedures,orovertreatment.However,personsemployedincertaincriticaloccupations,suchasaircraftpilots,[18]
mayberequiredtohaveanECGaspartoftheirroutinehealthevaluations.

ContinuousECGmonitoringisusedtomonitorcriticallyillpatients,patientsundergoinggeneralanesthesia,[15]
andpatientswhohaveaninfrequentlyoccurringcardiacdysrhythmiathatwouldbeunlikelytobeseenona
conventionaltensecondECG.

Performinga12leadECGintheUnitedStatesiscommonlyperformedbyspecializedtechniciansthatmaybe
certifiedelectrocardiogramtechnicians.ECGinterpretationisacomponentofmanyhealthcarefields(nursesand
physiciansandcardiacsurgeonsbeingthemostobvious)butanyonetrainedtointerpretanECGisfreetodoso.
However,"official"interpretationisperformedbyacardiologist.Certainfieldssuchasanesthesiautilize
continuousECGmonitoringandknowledgeofinterpretingECGsiscrucialtotheirjobs.

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Oneadditionalformofelectrocardiographyisusedinclinicalcardiacelectrophysiologyinwhichacatheterisused
tomeasuretheelectricalactivity.Thecatheterisinsertedthroughthefemoralveinandcanhaveseveralelectrodes
alongitslengthtorecordthedirectionofelectricalactivityfromwithintheheart..

Electrocardiographs
Anelectrocardiographisamachinethatisusedtoperform
electrocardiography,andproducestheelectrocardiogram.The
firstelectrocardiographsarediscussedaboveandare
electricallyprimitivecomparedtotoday'smachines.

Thefundamentalcomponenttoelectrocardiographisthe
Instrumentationamplifier,whichisresponsiblefortakingthe
voltagedifferencebetweenleads(seebelow)andamplifying
thesignal.ECGvoltagesmeasuredacrossthebodyareonthe
orderofhundredsofmicrovoltsupto1millivolt(thesmall
squareonastandardECGis100microvolts).Thislowvoltage
necessitatesalownoisecircuitandinstrumentationamplifiers
arekey.

Earlyelectrocardiographswereconstructedwithanalog
electronicsandthesignalcoulddriveamotortoprintthe
signalonpaper.Today,electrocardiographsuseanalogto
digitalconverterstoconverttoadigitalsignalthatcanthenbe
manipulatedwithdigitalelectronics.Thispermitsdigital
recordingofECGsanduseoncomputers.
Anelectrocardiographwithintegrateddisplayand
Thereareothercomponentstotheelectrocardiograph:[19] keyboardonawheeledcart

Safetyfeaturesthatincludevoltageprotectionforthe
patientandoperator.Sincethemachinesarepoweredbymainspower,itisconceivablethateitherperson
couldbesubjectedtovoltagecapableofcausingdeath.Additionally,theheartissensitivetotheAC
frequenciestypicallyusedformainspower(50or60Hz).
Defibrillationprotection.AnyECGusedinhealthcaremaybeattachedtoapersonwhorequires
defibrillationandtheelectrocardiographneedstoprotectitselffromthissourceofenergy.
Electrostaticdischargeissimilartodefibrillationdischargeandrequiresvoltageprotectionupto18,000
volts.
Additionallycircuitrycalledtherightlegdrivercanbeusedtoreducecommonmodeinterference(typically
the50/60Hzmainspower).

Typicaldesignforaportableelectrocardiographisacombinedunitthatincludesascreen,keyboard,andprinteron
asmallwheeledcart.Theunitconnectstoalongcablethatbranchestoeachleadwhichattachestoaconductive
padonthepatient.

Lastly,theelectrocardiographmayincludearhythmanalysisalgorithmthatproducesacomputerizedinterpretation
oftheelectrocardiogram.Theresultsfromthesealgorithmsareconsidered"preliminary"untilverifiedand/or
modifiedbysomeonetrainedininterpretingelectrocardiograms.Includedinthisanalysisiscomputationof
commonparametersthatincludePRinterval,QTduration,correctedQT(QTc)duration,PRaxis,QRSaxis,and
more.Earlierdesignsrecordedeachleadsequentiallybutcurrentdesignsemploycircuitsthatcanrecordallleads
simultaneously.Theformerintroducesproblemsininterpretationsincetheremaybebeattobeatchangesinthe
rhythmthatmakesitunwisetocompareacrossbeats.

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Electrodesandleads
A"lead"isnotthesameasan"electrode".Whereasanelectrodeisa
conductivepadincontactwiththebodythatmakesanelectricalcircuit
withtheelectrocardiograph,aleadisaconnectortoanelectrode.Since
leadscansharethesameelectrode,astandard12leadEKGhappensto
needonly10electrodes(aslistedinthetablebelow).

Aleadisslightlymoreabstractandisthesourceofmeasurementofa
vector.Forthelimbleads,theyare"bipolar"andarethecomparison
betweentwoelectrodes.Fortheprecordialleads,theyare"unipolar"and
comparedtoacommonlead(commonlytheWilson'scentralterminal),as Properplacementofthelimb
electrodes.Thelimbelectrodescanbe
describedbelow.[21]
fardownonthelimbsorclosetothe
Leadsarebrokendownintothreesets:limbaugmentedlimband hips/shouldersaslongastheyare
precordial.The12leadEKGhasatotalofthreelimbleadsandthree placedsymmetrically. [20]
augmentedlimbleadsarrangedlikespokesofawheelinthecoronalplane
(vertical)andsixprecordialleadsthatlieontheperpendiculartransverse
plane(horizontal).

Inmedicalsettings,thetermleadsisalsosometimesusedtorefertothe
electrodesthemselves,althoughthisisnottechnicallyacorrectusageofthe
term,whichcomplicatestheunderstandingofdifferencebetweenthetwo.

The10electrodesina12leadEKGarelistedbelow.

Electrode
Electrodeplacement
name
RA Ontherightarm,avoidingthickmuscle.
InthesamelocationwhereRAwasplaced,butontheleft
LA
arm.
Ontherightleg,lowerendofmedialaspectofcalfmuscle.
RL
(Avoidbonyprominences)
Placementoftheprecordial
LL InthesamelocationwhereRLwasplaced,butontheleftleg.
electrodes.
V1 Inthefourthintercostalspace(betweenribs4and5)justto
therightofthesternum(breastbone).
V2 Inthefourthintercostalspace(betweenribs4and5)justto
theleftofthesternum.
V3 BetweenleadsV2andV4.

V4 Inthefifthintercostalspace(betweenribs5and6)inthemid
clavicularline.
V5 HorizontallyevenwithV4,intheleftanterioraxillaryline.
V6 HorizontallyevenwithV4andV5inthemidaxillaryline.

Twocommonelectrodesusedareaflatpaperthinstickerandaselfadhesivecircularpad.Theformeraretypically
usedinasingleECGrecordingwhilethelatterareforcontinuousrecordingsastheysticklonger.Eachelectrode
consistsofanelectricallyconductiveelectrolytegelandasilver/silverchlorideconductor.[22]Thegeltypically

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containspotassiumchloridesometimessilverchlorideaswelltopermitelectronconductionfromtheskinto
thewireandtotheelectrocardiogram.

Thecommonlead,Wilson'scentralterminalVW,isproducedbyaveragingthemeasurementsfromtheelectrodes
RA,LA,andLLtogiveanaveragepotentialacrossthebody:

Ina12leadECG,allleadsexceptthelimbleadsareunipolar(aVR,aVL,aVF,V1,V2,V3,V4,V5,andV6).The
measurementofavoltagerequirestwocontactsandso,electrically,theunipolarleadsaremeasuredfromthe
commonlead(negative)andtheunipolarlead(positive).Thisaveragingforthecommonleadandtheabstract
unipolarleadconceptmakesforamorechallengingunderstandingandiscomplicatedbysloppyusageof"lead"
and"electrode".

Limbleads

LeadsI,IIand
IIIarecalledthe
limbleads.The
electrodesthat
formthese
signalsare
locatedonthe
limbsoneon
eacharmand
oneontheleft
leg.[23][24][25]
Thelimbleads
formthepoints
ofwhatis
knownas
Einthoven's
triangle.[26]

LeadIis
the
voltage
between
the Thelimbleadsandaugmentedlimbleads
(positive)
leftarm
(LA)electrodeandrightarm(RA)electrode:

LeadIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtherightarm(RA)electrode:

LeadIIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtheleftarm(LA)electrode:

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Augmentedlimbleads

LeadsaVR,aVL,andaVFaretheaugmentedlimbleads.They
arederivedfromthesamethreeelectrodesasleadsI,II,and
III,buttheyuseGoldberger'scentralterminalastheirnegative
pole.Goldberger'scentralterminalisacombinationofinputs
fromtwolimbelectrodes,withadifferentcombinationfor
eachaugmentedlead.Itisreferredtoimmediatelybelowas
"thenegativepole".

Leadaugmentedvectorright(aVR)'hasthepositive
electrodeontherightarm.Thenegativepoleisa
combinationoftheleftarmelectrodeandtheleftleg
electrode:

Leadaugmentedvectorleft(aVL)hasthepositiveelectrodeontheleftarm.Thenegativepoleisa
combinationoftherightarmelectrodeandtheleftlegelectrode:

Leadaugmentedvectorfoot(aVF)hasthepositiveelectrodeontheleftleg.Thenegativepoleisa
combinationoftherightarmelectrodeandtheleftarmelectrode:

TogetherwithleadsI,II,andIII,augmentedlimbleadsaVR,aVL,andaVFformthebasisofthehexaxial
referencesystem,whichisusedtocalculatetheheart'selectricalaxisinthefrontalplane.

Precordialleads

Theprecordialleadslieinthetransverse(horizontal)plane,perpendiculartotheothersixleads.Thesixprecordial
electrodesactasthepositivepolesforthesixcorrespondingprecordialleads:(V1,V2,V3,V4,V5andV6).
Wilson'scentralterminalisusedasthenegativepole.

Specializedleads

Additionalelectrodesmayrarelybeplacedtogenerateotherleadsforspecificdiagnosticpurposes.Rightsided
precordialleadsmaybeusedtobetterstudypathologyoftherightventricleorfordextrocardia(andaredenoted
withanR(e.g.,V5R)).Posteriorleads(V7toV9)maybeusedtodemonstratethepresenceofaposterior
myocardialinfarction.ALewislead(requiringanelectrodeattherightsternalborderinthesecondintercostal
space)canbeusedtostudypathologicalrhythmsarisingintherightatrium.

Anesophogealleadcanbeinsertedtoapartoftheesophaguswherethedistancetotheposteriorwalloftheleft
atriumisonlyapproximately56mm(remainingconstantinpeopleofdifferentageandweight).[27]An
esophagealleadavailsforamoreaccuratedifferentiationbetweencertaincardiacarrhythmias,particularlyatrial
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flutter,AVnodalreentranttachycardiaandorthodromicatrioventricularreentranttachycardia.[28]Itcanalso
evaluatetheriskinpeoplewithWolffParkinsonWhitesyndrome,aswellasterminatesupraventricular
tachycardiacausedbyreentry.[28]

Anintracardiacelectrogram(ICEG)isessentiallyanECGwithsomeaddedintracardiacleads(thatis,insidethe
heart).ThestandardECGleads(externalleads)areI,II,III,aVL,V1,andV6.Twotofourintracardiacleadsare
addedviacardiaccatheterization.Theword"electrogram"(EGM)withoutfurtherspecificationusuallymeansan
intracardiacelectrogram.

LeadlocationsonanECGreport

Astandard12leadECGreport(anelectrocardiograph)showsa2.5secondtracingofeachofthetwelveleads.The
tracingsaremostcommonlyarrangedinagridoffourcolumnsandthreerows.thefirstcolumnisthelimbleads
(I,II,andIII),thesecondcolumnistheaugmentedlimbleads(aVR,aVL,andaVF),andthelasttwocolumnsare
theprecordialleads(V1V6).Additionally,arhythmstripmaybeincludedasafourthorfifthrow.

Thetimingacrossthepageiscontinuousandnottracingsofthe12leadsforthesametimeperiod.Inotherwords,
iftheoutputweretracedbyneedlesonpaper,eachrowwouldswitchwhichleadsasthepaperispulledunderthe
needle.Forexample,thetoprowwouldfirsttraceleadI,thenswitchtoleadaVR,thenswitchtoV1,andthen
switchtoV4andsononeofthesefourtracingsoftheleadsarefromthesametimeperiodastheyaretracedin
sequencethroughtime.

Contiguityofleads

Eachofthe12ECGleadsrecordstheelectricalactivityofthe
heartfromadifferentangle,andthereforealignwithdifferent
anatomicalareasoftheheart.Twoleadsthatlookat
neighboringanatomicalareasaresaidtobecontiguous.

Category Leads Activity

Leads
Lookatelectricalactivityfromthevantage
Inferior II,III
pointoftheinferiorsurface(diaphragmatic
leads' and
surfaceofheart) Diagramshowingthecontiguousleadsinthesame
aVF
colorinthestandard12leadlayout
I,
aVL, Lookattheelectricalactivityfromthe
Lateral V5 vantagepointofthelateralwallofleft
leads
and ventricle
V6
V1 Lookatelectricalactivityfromthevantage
Septal
and pointoftheseptalsurfaceoftheheart
leads
V2 (interventricularseptum)

V3 Lookatelectricalactivityfromthevantage
Anterior pointoftheanteriorwalloftherightand
and
leads leftventricles(Sternocostalsurfaceof
V4
heart)

Inaddition,anytwoprecordialleadsnexttooneanotherareconsideredtobecontiguous.Forexample,thoughV4
isananteriorleadandV5isalaterallead,theyarecontiguousbecausetheyarenexttooneanother.
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Electrophysiology
Theformalstudyoftheelectricalconductionsystemoftheheartiscalledcardiacelectrophysiology(EP).An
electrophysiologystudyinvolvesaformalstudyoftheconductionsystemandcanbedoneforvariousreasons.
Duringsuchastudy,cathetersareusedtoaccesstheheartandsomeofthesecathetersincludeelectrodesthatcan
beplacedanywhereinthehearttorecordtheelectricalactivityfromwithintheheart.Somecatheterscontain
severalelectrodesandcanrecordthepropagationofelectricalactivity.

Interpretation
InterpretationoftheECGisfundamentallyaboutunderstandingtheelectricalconductionsystemoftheheart.
Normalconductionstartsandpropagatesinapredictablepattern,anddeviationfromthispatterncanbeanormal
variationorbepathological.AnECGdoesnotequatewithmechanicalpumpingactivityoftheheart,forexample,
pulselesselectricalactivityproducesanECGthatshouldpumpbloodbutnopulsesarefelt(andconstitutesa
medicalemergencyandCPRshouldbeperformed).VentricularfibrillationproducesanECGbutistoo
dysfunctionaltoproducealifesustainingcardiacoutput.Certainrhythmsareknowntohavegoodcardiacoutput
andsomeareknowntohavebadcardiacoutput.Ultimately,anechocardiogramorotheranatomicalimaging
modalityisusefulinassessingthemechanicalfunctionoftheheart.

Likeallmedicaltests,whatconstitutes"normal"isbasedonpopulationstudies.Theheartraterangeofbetween60
and100isconsiderednormalsincedatashowsthistobetheusualrestingheartrate.

Theory

InterpretationoftheECGisultimatelythatofpatternrecognition.In
ordertounderstandthepatternsfound,itishelpfultounderstandthe
theoryofwhatECGsrepresent.Thetheoryisrootedinelectromagnetics
andboilsdowntothefourfollowingpoints:

depolarizationofthehearttowardthepositiveelectrodeproducesa
positivedeflection
depolarizationoftheheartawayfromthepositiveelectrode
producesanegativedeflection
repolarizationofthehearttowardthepositiveelectrodeproducesa
negativedeflection
repolarizationoftheheartawayfromthepositiveelectrode
producesapositivedeflection

Thus,theoveralldirectionofdepolarizationandrepolarizationproducesa QRSisuprightinaleadwhenitsaxis
vectorthatproducespositiveornegativedeflectionontheECG isalignedwiththatlead'svector
dependingonwhichleaditpointsto.Forexample,depolarizingfrom
righttoleftwouldproduceapositivedeflectioninleadIbecausethetwovectorspointinthesamedirection.In
contrast,thatsamedepolarizationwouldproduceminimaldeflectioninV1andV2becausethevectorsare
perpendicularandthisphenomenoniscalledisoelectric.

NormalrhythmproducesfourentitiesaPwave,aQRScomplex,aTwave,andaUwavethateachhavea
fairlyuniquepattern.

ThePwaverepresentsatrialdepolarization.
TheQRScomplexrepresentsventriculardepolarization.
TheTwaverepresentsventricularrepolarization.

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TheUwaverepresentspapillarymusclerepolarization.

However,theUwaveisnottypicallyseenanditsabsenceis
generallyignored.Changesinthestructureoftheheartandits
surroundings(includingbloodcomposition)changethepatterns
ofthesefourentities.

Electrocardiogramgrid

ECG'sarenormallyprintedonagrid.Thehorizontalaxis
representstimeandtheverticalaxisrepresentsvoltage.The
standardvaluesonthisgridareshownintheadjacentimage:

Asmallboxis1mmx1mmbigandrepresents0.1mVx SchematicrepresentationofnormalECG
0.04seconds.
Alargeboxis5mmx5mmbigandrepresents0.5mVx0.2secondswide.

The"large"boxisrepresentedbyaheavierlineweightthanthesmallboxes.

NotallaspectsofanECGrelyonpreciserecordingsorhavingaknownscalingofamplitudeortime.Forexample,
determiningifthetracingisasinusrhythmonlyrequiresfeaturerecognitionandmatching,andnotmeasurement
ofamplitudesortimes(i.e.,thescaleofthegridsareirrelevant).Anexampletothecontrary,thevoltage
requirementsofleftventricularhypertrophyrequireknowingthegridscale.

Rateandrhythm

Inanormalheart,theheartrateistherateinwhichthesinoatrialnodedepolarizesasitisthesourceof
depolarizationoftheheart.Heartrate,likeothervitalsignslikebloodpressureandrespiratoryrate,changewith
age.Inadults,anormalheartrateisbetween60and100beatsperminute(normocardic)whereinchildrenitis
higher.Aheartratelessthannormaliscalledbradycardia(<60inadults)andhigherthannormalistachycardia

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(>100inadults).Acomplicationofthisiswhentheatriaandventriclesarenotinsynchronyandthe"heartrate"
mustbespecifiedasatrialorventricular(e.g.,atrialrateinatrialfibrillationis300600bpm,whereasventricular
ratecanbenormal(60100)orfaster(100150)).

Innormalrestinghearts,thephysiologicrhythmoftheheartisnormalsinusrhythm(NSR).Normalsinusrhythm
producestheprototypicalpatternofPwave,QRScomplex,andTwave.Generally,deviationfromnormalsinus
rhythmisconsideredacardiacarrhythmia.Thus,thefirstquestionininterpretinganECGiswhetherornotthereis
asinusrhythm.AcriterionforsinusrhythmisthatPwavesandQRScomplexesappear1to1,thusimplyingthat
thePwavecausestheQRScomplex.

Oncesinusrhythm,ornot,isestablishedthesecondquestionistherate.Forasinusrhythmthisiseithertherateof
PwavesorQRScomplexessincetheyare1to1.Iftherateistoofastthenitissinustachycardiaandifitistoo
slowthenitissinusbradycardia.

Ifitisnotasinusrhythm,thendeterminingtherhythmisnecessarybeforeproceedingwithfurtherinterpretation.
Somearrhythmiaswithcharacteristicfindings:

AbsentPwaveswith"irregularlyirregular"QRScomplexesisthehallmarkofatrialfibrillation
A"sawtooth"patternwithQRScomplexesisthehallmarkofatrialflutter
Sinewavepatternisthehallmarkofventricularflutter
AbsentPwaveswithwideQRScomplexeswithfastrateisventriculartachycardia

Determinationofrateandrhythmisnecessaryinordertomakesenseoffurtherinterpretation.

Axis

Thehearthasseveralaxes,butthemostcommonbyfaristheaxisoftheQRScomplex(referencesto"theaxis"
implicitlymeanstheQRSaxis).Eachaxiscanbecomputationallydeterminedtoresultinanumberrepresenting
degreesofdeviationfromzero,oritcanbecategorizedintoafewtypes.

TheQRSaxisisthegeneraldirectionoftheventriculardepolarizationwavefront(ormeanelectricalvector)inthe
frontalplane.Itisoftensufficienttoclassifytheaxisasoneofthreetypes:normal,leftdeviated,orrightdeviated.
PopulationdatashowsthatnormalQRSaxisisfrom30to105with0beingalongleadIandpositivebeing
inferiorandnegativebeingsuperior(bestunderstoodgraphicallyasthehexaxialreferencesystem).[29]Beyond
+105isrightaxisdeviationandbeyond30isleftaxisdeviation(thethirdquadrantof90to180isvery
rareandisanindeterminateaxis).AshortcutfordeterminingiftheQRSaxisisnormalisiftheQRScomplexis
mostlypositiveinleadIandleadII(orleadIandaVFif+90istheupperlimitofnormal).

ThenormalQRSaxisisgenerallydownandtotheleft,followingtheanatomicalorientationoftheheartwithinthe
chest.Anabnormalaxissuggestsachangeinthephysicalshapeandorientationoftheheart,oradefectinits
conductionsystemthatcausestheventriclestodepolarizeinanabnormalway.

Classification Angle Notes

30to
Normal Normal
105
Leftaxis 30to Mayindicateleftventricularhypertrophy,leftanteriorfascicularblock,oranold
deviation 90 inferiorqwavemyocardialinfarction
Rightaxis +105to Mayindicaterightventricularhypertrophy,leftposteriorfascicularblock,oranold
deviation +180 lateralqwavemyocardialinfarction
Indeterminate +180to
Rarelyseenconsideredan'electricalnoman'sland'
axis 90
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Theextentofnormalaxiscanbe+90or105dependingonthesource.

Amplitudesandintervals

AllofthewavesonanEKGtracingandtheintervalsbetweenthemhavea
predictabletimeduration,arangeofacceptableamplitudes(voltages),and
atypicalmorphology.Anydeviationfromthenormaltracingispotentially
pathologicalandthereforeofclinicalsignificance.

Foreaseofmeasuringtheamplitudesandintervals,anEKGisprintedon
graphpaperatastandardscale:each1mm(onesmallboxonthestandard
EKGpaper)represents40millisecondsoftimeonthexaxis,and0.1
millivoltsontheyaxis.

AnimationofanormalECGwave

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Feature Description Pathology Duration

Thepwaverepresents
Thepwaveistypicallyuprightinmostleadsexceptfor
depolarizationoftheatria.
aVRanunusualpwaveaxis(invertedinotherleads)can
Atrialdepolarizationspreads
indicateanectopicatrialpacemaker.Ifthepwaveisof
Pwave fromtheSAnodetowards <80ms
unusuallylongduration,itmayrepresentatrialenlargement.
theAVnode,andfromthe
Typicallyalargerightatriumgivesatall,peakedpwave
rightatriumtotheleft
whilealargeleftatriumgivesatwohumpedbifidpwave.
atrium.
ThePRintervalismeasured
APRintervalshorterthan120mssuggeststhattheelectrical
fromthebeginningoftheP
impulseisbypassingtheAVnode,asinWolfParkinson
wavetothebeginningofthe
Whitesyndrome.APRintervalconsistentlylongerthan200
PR QRScomplex.Thisinterval 120to
msdiagnosesfirstdegreeatrioventricularblock.ThePR
interval reflectsthetimethe 200ms
segment(theportionofthetracingafterthepwaveand
electricalimpulsetakesto
beforetheQRScomplex)istypicallycompletelyflat,but
travelfromthesinusnode
maybedepressedinpericarditis.
throughtheAVnode.
TheQRScomplexrepresents IftheQRScomplexiswide(longerthan120ms)itsuggests
therapiddepolarizationof disruptionoftheheart'sconductionsystem,suchasin
therightandleftventricles. LBBB,RBBB,orventricularrhythmssuchasventricular
Theventricleshavealarge tachycardia.Metabolicissuessuchasseverehyperkalemia,
QRS 80to100
musclemasscomparedto orTCAoverdosecanalsowidentheQRScomplex.An
complex ms
theatria,sotheQRS unusuallytallQRScomplexmayrepresentleftventricular
complexusuallyhasamuch hypertrophywhileaverylowamplitudeQRScomplexmay
largeramplitudethantheP representapericardialeffusionorinfiltrativemyocardial
wave. disease.
TheJpointisthepointat TheJpointmaybeelevatedasanormalvariant.The
whichtheQRScomplex appearanceofaseparateJwaveorOsbornwaveattheJ
Jpoint
finishesandtheSTsegment
pointispathognomonicofhypothermiaorhypercalcemia.[30]
begins.
TheSTsegmentconnects Itisusuallyisoelectric,butmaybedepressedorelevated
theQRScomplexandtheT withmyocardialinfarctionorischemia.STdepressioncan
ST
waveitrepresentsthe alsobecausedbyLVHordigoxin.STelevationcanalsobe
segment
periodwhentheventricles causedbypericarditis,Brugadasyndrome,orcanbea
aredepolarized. normalvariant(Jpointelevation).
TheTwaverepresentsthe
InvertedTwavescanbeasignofmyocardialischemia,
repolarizationofthe
LVH,highintracranialpressure,ormetabolicabnormalities.
Twave ventricles.Itisgenerally 160ms
PeakedTwavescanbeasignofhyperkalemiaorveryearly
uprightinallleadsexcept
myocardialinfarction.
aVRandleadV1.
TheQTintervalismeasured
fromthebeginningofthe
QRScomplextotheendof
Corrected AprolongedQTcintervalisariskfactorforventricular
theTwave.Acceptable
QT tachyarrhythmiasandsuddendeath.LongQTcanariseasa
rangesvarywithheartrate, <440ms
interval geneticsyndrome,orasasideeffectofcertainmedications.
soitmustbecorrectedtothe
(QTc) AnunusuallyshortQTccanbeseeninseverehypercalcemia.
QTcbydividingbythe
squarerootoftheRR
interval.
Uwave TheUwaveishypothesized IftheUwaveisveryprominent,suspecthypokalemia,
tobecausedbythe hypercalcemiaorhyperthyroidism.[31]
repolarizationofthe
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interventricularseptum.It
normallyhasalow
amplitude,andevenmore
ofteniscompletelyabsent.

Ischemiaandinfarction

IschemiaornonSTelevationmyocardialinfarctionsmaymanifestasSTdepressionorinversionofTwaves.It
mayalsoaffectthehighfrequencybandoftheQRS.

STelevationmyocardialinfarctionshavedifferentcharacteristicECGfindingsbasedontheamountoftime
elapsedsincetheMIfirstoccurred.TheearliestsignishyperacuteTwaves,peakedTwavesduetolocal
hyperkalemiainischemicmyocardium.ThisthenprogressesoveraperiodofminutestoelevationsoftheST
segmentbyatleast1mm.Overaperiodofhours,apathologicQwavemayappearandtheTwavewillinvert.
OveraperiodofdaystheSTelevationwillresolve.Pathologicqwavesgenerallywillremainpermanently.[32]

ThecoronaryarterythathasbeenoccludedcanbeidentifiedinanSTelevationmyocardialinfarctionbasedonthe
locationofSTelevation.TheLADsuppliestheanteriorwalloftheheart,andthereforecausesSTelevationsin
anteriorleads(V1andV2).TheLCxsuppliesthelateralaspectoftheheartandthereforecausesSTelevationsin
lateralleads(I,aVLandV6).TheRCAusuallysuppliestheinferioraspectoftheheart,andthereforecausesST
elevationsininferiorleads(II,IIIandaVF).

Artifacts

AnEKGtracingisaffectedbypatientmotion.Somerhythmicmotions(suchasshiveringortremors)cancreate
theillusionofcardiacdysrhythmia.[33]Artifactsaredistortedsignalscausedbyasecondaryinternalorexternal
sources,suchasmusclemovementorinterferencefromanelectricaldevice.[34][35]

Distortionposessignificantchallengestohealthcareproviders,[34]whoemployvarioustechniques[36]and
strategiestosafelyrecognize[37]thesefalsesignals.AccuratelyseparatingtheECGartifactfromthetrueECG
signalcanhaveasignificantimpactonpatientoutcomesandlegalliabilities.[38]

Improperleadplacement(forexample,reversingtwoofthelimbleads)hasbeenestimatedtooccurin0.4%to4%
ofallEKGrecordings,[39]andhasresultedinimproperdiagnosisandtreatmentincludingunnecessaryuseof
thrombolytictherapy.[40][41]

Diagnosis
Numerousdiagnosisandfindingscanbemadebaseduponelectrocardiographyandmanyarediscussedabove.The
followingisanorganizedlistoftheseandmore.

Rhythmdisturbances/Arrhythmias:

Atrialfibrillation&atrialflutterwithoutrapidventricularresponse
Prematureatrialcontraction(PACs)&Prematureventricularcontraction(PVCs)
Sinusarrhythmia
Sinusbradycardia&sinustachycardia
Sinuspause&sinoatrialarrest
Sicksinussyndrome:bradycardiatachycardiasyndrome
Supraventriculartachycardia
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Atrialfibrillation(afib)withrapidventricularresponse
Atrialflutterwithrapidventricularresponse
AVnodalreentranttachycardia
Atrioventricularreentranttachycardia
Junctionalectopictachycardia
Atrialtachycardia
Ectopicatrialtachycardia(unicentric)
Multifocalatrialtachycardia
Paroxysmalatrialtachycardia
Sinoatrialnodalreentranttachycardia
Torsadesdepointes(polymorphicventriculartachycardia)
Widecomplextachycardia
Ventricularflutter
Ventricularfibrillation
Ventriculartachycardia(monomorphicventriculartachycardia)
Preexcitationsyndrome
WolffParkinsonWhitesyndrome

Heartblockandconductionproblems:

Aberration
Brugadasyndrome
FirstdegreeAVblock,SeconddegreeAVblock(MobitzI&II),ThirddegreeAVblock
Leftanterior&leftposteriorfascicularblockbifasciularblockandtrifasciularblocks
Incompleteandcompleterightbundlebranchblock(RBBB)
IncompleteandcompleteLeftbundlebranchblock(LBBB)
LongQTsyndrome
Rightandleftatrialabnormality

Electrolytesdisturbances&intoxication:

Digitalisintoxication
Calcium:hypocalcemiaandhypercalcemia
Potassium:hypokalemiaandhyperkalemia

Ischemiaandinfarction:

STelevationandSTdepression
HighFrequencyQRSchanges
Myocardialinfarction(heartattack)
NonQwavemyocardialinfarction
NSTEMI
STEMI

Structural:

Acutepericarditis
Rightandleftventricularhypertrophy
Rightventricularstrain/S1Q3T3

Seealso
Electricalconductionsystemoftheheart
Electrogastrogram
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Electropalatography
Electroretinography
Heartratemonitor
Emergencymedicine

Notes
a.TheversionwithK,whichisrarerinBritishEnglishthaninAmericanEnglish,isanearly20thcenturyloanwordfrom
theGermanacronymEKGforElektrokardiogramm(electrocardiogram),[1]whichreflectsthatGermanphysicianswere
pioneersinthefieldatthetime.TodayAMAstyleand,underitsstylisticinfluence,mostAmericanmedicalpublications
useECGinsteadofEKG.[2]TheGermantermElektrokardiogrammaswellastheEnglishequivalentelectrocardiogram
consistoftheNewLatin/internationalscientificvocabularyelementselektro(cognateelectro)andkardi(cognate
cardi),thelatterfromGreekkardia(heart).[3]TheKversionismoreoftenretainedundercircumstanceswherethere
maybeverbalconfusionbetweenECGandEEG(electroencephalography)duetosimilarpronunciation.

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Externallinks
ThewholeECGcourseon1A4paper(http://www.ecgpedia.org/A4/
ECGpedia_on_1_A4En.pdf)fromECGpedia(http://en.ecgpedia.org/ WikimediaCommonshas
mediarelatedtoECG.
wiki/Main_Page),awikiencyclopediaforacourseoninterpretation
ofECG(http://en.ecgpedia.org/wiki/ECG_course)

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WaveMavenalargedatabaseofpracticeECGquestions(http://ecg.bidmc.harvard.edu/maven/mavenmain.
asp)providedbyBethIsraelDeaconessMedicalCenter
PysioBankafreescientificdatabasewithphysiologicsignals(hereecg)(http://www.physionet.org/physiob
ank/database/#ecg)

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