ELECTROCARDIOGRAM (ECG) | Tutorial D-1 CVS

130110110177|Gabriella Chafrina| 18/09/13

The heart consist of 3 types of cells:
Pace maker cells
Smalls cells approximately 5 to 20 um long
Able to depolarize spontaneously
1 electrical cycle of depolarization & repolarization = action potential
Dominant pace maker cells : sinoatrial (SA) node, which rate can vary
(: symphatetic stimulation, : vagal stimulation)

Electrical conducting cells
Long, thin cells
The electrical conducting cells of the ventricles join to form distinct electrical
pathways






Myocardial cells
Responsible for heavy labor of repeatedly contracting and relaxing
When a wave of depolarization reaches a myocardial cell, calcium
is released within the cell, causing the cell to contract. This process
is called excitation contraction coupling

Time and voltage
The waves reflect the electrical activity of the myocardial cells
Three chief characteristics of the waves: duration, amplitude, and configuration
EKG paper
Is a long, continuous roll of graph paper
The light lines = small squares of 1 x 1 mm
The dark lines = large squares of 5 x 5 mm
The horizontal axis measures time
1 small square = 0.04 s
1 large square = 0.04 s x 5 =0.2 s
The vertical axis measures voltage
1 small square = 0.1 mV
1 large small = 0.5 mV

Atrial Depolarization P Waves
The sinus node fires spontaneously and wave of depolarization begins to
spread outward into the atrial
P wave is a recording of the spread of depolarization through the atrial
myocardium from start to finish
1
st
part of the P wave right atrial depolarization
2
nd
part of the P wave left atrial depolarization

A Pause
A conduction pause separates the atria from the ventricles.
Atrioventricular (AV) mode slows conduction to allow the atria to finish contracting
before the ventricles begin to contract. So, its permit the atria to empty their volume of
blood completely into the ventricles before the ventricles contract.
Influence by ANS like SA node.
ELECTROCARDIOGRAM (ECG) | Tutorial D-1 CVS
130110110177|Gabriella Chafrina| 18/09/13
Ventricular Depolarization Ventricular Conducting Systsem + QRS complex
Ventricular conducting system
1/10s after depolarizing waves escapes AV node enter electrical conducting cell
consist of 3 part:
Bundle of His
This emerges from the AV node and divides into right and left bundle branches
Bundle branches
Right bundle branch carries the current down the right side of the
interventricular septum to the apex of the right ventricle
Left bundle branch divides into 3 major fascicles :
o Septal fascicle: depolarizes the interventricular septum in a left-to-right-
direction
o Anterior fascicle: runs along the anterior surface of the left ventricle
o Posterior fascicle: sweeps over the posterior
Terminal Purkinje fibers
Termination of the right and left ventricular branches and its fascicles. These
fibers deliver the electrical current into the ventricular myocardium

QRS complex
The beginning of ventricular myocardial depolarization and ventricular
contraction is marked by QRS complex
The amplitude of the QRS complex is greater that the P wave because
ventricles are larger than the atria
Parts of QRS complex:
First deflection downward Q wave.
First upward deflection R wave.
Second upward deflection R' (R-prime).
First downward deflection following an upward deflection S wave
If entire configuration consists of one downward deflection QS wave.
The earliest part of the QRS complex represents depolarization of the
interventricular septum by the septal fascicle of the left bundle branch
Myocardial cells depolarize pass through a brief refractory period
(resistant to the further stimulation) repolarize

Repolarization T waves
Myocardial cells depolarize pass through a brief refractory period (resistant to
the further stimulation) repolarize
Ventricular repolarization inscribes the T wave, third wave on ECG






Segments and Intervals
Segment : a starlight line connecting 2 waves
Interval : at last 1 wave + the connecting straight line
PR Interval : measures the time from the start of atrial depolarization to the start of ventricular depolarization
PR segment: measures the time from the end of atrial depolarization to the start of ventricular depolarization
ST segment : measures the time from the end of ventricular depolarization to the start of ventricular repolarization
QT interval : measures the time from the start of ventricular depolarization to the end of ventricular repolarization
QRS interval : measures the time of ventricular depolarization
ELECTROCARDIOGRAM (ECG) | Tutorial D-1 CVS
130110110177|Gabriella Chafrina| 18/09/13
Making Waves
A wave of depolarization moving toward a positive electrode causes a positive deflection on the EKG
A wave of depolarization moving away from a positive electrode causes a negative deflection on the EKG
A wave of repolarization moving toward from a positive electrode cause a negative deflection on the EKG
A wave of repolarization moving away from a positive electrode causes a positive deflection on the EKG
A perpendicular wave produces a biphasic wave

12 lead EKG
6 limb leads: view the heart in the vertical plane called the frontal plane
3 standard leads
Lead I
The left arm positive and the right arm negative
Angle of orientation: 0
o
Lead II
The legs positive and the right arm negative
Angle of orientation: 60
o
Lead III
The legs positive and the right arm negative
Angle of orientation: 120
o
3 augmented leads
Lead AVL
The left arm positive and the other limbs negative
Angle of orientation: -30
o
Lead AVR
The right arm positive and the other limbs negative
Angle of orientation: -150
o
Lead AVF
The legs positive and the other limbs negative
Angle of orientation: +90
0













6 precordial leads in a horizontal plane
V1 : 4
th
intercostals space to the right of the sternum
V2 : 4
th
intercostals spave to the left sternum
V3 : between V2 an V4
V4 : 5
th
intercostals space in the midclavicular line
V5 : between V4 and V5
V6 : 5
th
intercostals space in the misaxillary line

Anterior groups : Leads V1, V2, V3, V4
Inferior groups : Leads II, III, AVF
Left lateral goups : leads I, AVL, V5, V6
ELECTROCARDIOGRAM (ECG) | Tutorial D-1 CVS
130110110177|Gabriella Chafrina| 18/09/13

Definition: partial intraventricular block every other heartbeat that make regular alternating amplitude, direction, or
configuration of the QRS complexes in any or all leads
- The RR intervals remain unchanged (regular)
- Total electrical alternans refers to involvement of the P, QRS, and T waves and occasionally the U wave

Etiology:
Alternans of the QRS complex is rare in patients with cardiac tamponade and occurs in some patients with a lrge
pericardial effusion, particularly with malignancy
Total electrical alternans is almost diagnostic of cardiac tampinade, although it occurs in fewer than 10% of patients
with tamponade and may be associated with a swinging heart on echocardiography
Severe coronary artery and hypertrophic heart disease is a reare cause of electrical alternans
Supraventricular tachycardia with a very rapid ventricular rate, mainly occurring in patients with Wolff-Parkinson-White
syndrome (orthodromic) reentrant tachycardia, is another cause
conditions that depress the heart (ex: ischemia, myocarditis, or digitalis toxixity) can cause incomplete intraventricular
heart block

Pathophysiology:
The pathophysiologic mechanisms that cause electrical alternans can be divided into 3 categories
o Repolarization alternans (ST, T, U alternans)
o Conduction and refractoriness alternans (P, PR, QRS alternans)
o Alternans due to cardiac motion
True electrical alternans is a repolarization or conduction abnormality of the Purkinje fibers or myocardium
Electrical alternans due to cardiac motion is effectively artifact, as the heart swings in relation to the chest wall and
electrodes, with a period twice that of the heart rate.

- In pericarditis, if effusion sufficiently large heart may actually rotate freely within the fluid filled sac/heart swing
electric axis keep changes when ECG Electrical alternans
- Rapid heart rate impossible for some Purkinje system to recover from previous refractory period quickly enough to
respond during every succeeding heart beat








Reference:
M. Gabriel Khan; Rapid ECG Interpretation
Malcolm S. Thaler; The Only EKG Book Youll Ever Need
Scott W. Sharkey; A Guide to Interpretation of Hemodynamic Data in The Coronary Unit