The normal electrocardiogram

Erwinanto
Div. Of Cardiology, Dept. of Internal Medicine
Padjadjaran University School of Medicine
Hasan Sadikin Hospital
Bandung
Introduction
What medical problems can be
diagnosed with an ECG?

• Enlargement of cardiac chambers

• Hypertrophy of cardiac muscle
• Cardiac arrhythmias
• Insufficient coronary blood flow
• Death of heart muscle and its location
• Electrolyte abnormality
 What is an Electrocardiogram?

An ECG is the recording (“gram”) of the

electrical activity (“electro”) of the cells of the
heart (“cardio”) that reaches the body surface

Initiates the heart muscle to contract, to

pump blood to the tissues
 What does an ECG actually measure?

An ECG records voltage on its vertical axis

against time on its horizontal axis

• Measurement along the vertical axis indicates

“summation” of the electrical activation of all of the
cardiac cells
• Measurement along the horizontal axis indicates
heart rate, regularity, and the time intervals
required for electrical activity to move from one
part of the heart to another
Electrical activity of the heart
+ + + + + + + +
– – – – – – – – – – – –
+ + + + + + + +

+ + – – – + + + +
– – – + + + – – – – – –
+ + – – – + + + +

– – – – – – – – – – – –
+ + + + + + + + + + + +
– – – – – – – – – – – –
– – – – – – – – – – – –
+ + + + + + + + + + + +
– – – – – – – – – – – –

– – – + + – – – – – –
+ + + – – – + + + + + +
– – – + + – – – – – –

+ + + + + + + +
– – – – – – – – – – – –
+ + + + + + + +
 + + – – – + +
– – – + + + – – –
+ + – – – + +

+
0
–

+
–
 Terms describing cardiac cycle

Systole Diastole
Activation Recovery

Electrical Excitation Recovery

Depolarization Repolarization

Shortening Lengthening

Mechanical Contraction Relaxation

Emptying Filling
 LA
(HB)
RA
(SAN) V
V (BB)
(AVN)

(BB)

HB

SAN AVN BB

RA
LA
V
Recording the electrocardiogram
 RECORDING ELECTRODES AND LEADS

1. Bipolar limb leads:

record the potential differences between two limbs

2. Unipolar precordial leads:

record the absolute electrical potential at each of

designated torso sites

3. Augmented unipolar limb leads:

is designed to increase the amplitude of the output

of limb leads
BIPOLAR LIMBS LEADS
Lead I Left arm
Positive
Lead II Left leg
input
Lead III Left leg
AUGMENTED UNIPOLAR LIMBS LEADS
aVR Right arm
Positive
aVL Left arm
input
aVF Left leg
PRECORDIAL LEADS
V1 Right sternal margin, 4th intercostal space
V2 Left sternal margin, 4th intercostal space
V3 Midway between V2 and V4
V4 Left midclavicular line, 5th intercostal space
V5 Left anterior axillary line

V6 Left midaxillary line

Reading the electrocardiogram
R R R

Q S

R R

R’

Q S QS S
Systematic evaluation of the ECG

1. Rate and regularity

2. P-wave morphology
3. PR interval
4. QRS-complex morphology
5. ST-segment morphology
6. T-wave morphology
7. U-wave morphology
8. QTc interval
9. Rythm
Rate and regularity
 P waves and QRS complexes are used to determine
cardiac rate and regularity
 Over a particular interval of time, normally, there
are same numbers of P waves and QRS complexes
 Heart rate:
 * 1500 divided by number of small squares
between successive P waves or QRS
complexes
* 300 divided by number of large squares
between successive P waves or QRS
complexes
 Normal heart rate: 60-100 beats per minute (bpm)
P-wave morphology
1. The contour: is normally smooth and monophasic

(entirely positive or negative) in all leads except V1

or occasionally V2

2. Upright or positive P waves are normally seen in

leads I, aVL, aVF, V4-V6 and downward in lead aVR.

P wave in lead III may be either upright or downward.

3. P-wave duration is normally less than 0.12 seconds

4. The maximal amplitude is normally no more than 0.2

mv
Abnormal P waves
The PR interval
1. The PR interval measures the time required for an

electrical impulse to travel from the atrial

myocardium adjacent to the SA node to the

ventricular myocardium adjacent to the fibers of

the Purkinye network

2. The duration is normally from 0.11 to 0.20 seconds

3. PR interval varies with the heart rate. The faster

the heart rate, the shorter the PR interval

Abnormal PR interval
Morphology of the QRS
complex
1. Q waves.

• The presence of Q waves in leads V1, V2, and

V3 should be consider abnormal.

• The absence of small Q waves in leads V5 and

V6 should be consider abnormal

• A Q wave of any size is normal in leads III and

avR

• In all other leads, a “normal” Q wave would be

very small (less than 0.04 second and its
voltage is less than 25% of the R-wave)
Anbormal Q waves
2. R waves

The positive R wave normally increases in

amplitude and duration from lead V1 to V4 or V5.

Loss of normal R-wave progression is considered

abnormal

3. S wave

S wave should be large in V1 and then

progressively smaller to V6

4. Ratio of R/S amplitude in V1 and V2 is normally

less than 1
Abnormal R wave in V1
5. Duration of the QRS complex (QRS interval)

It normally ranges from 0.07 second to 0.11

second (less than 0.12 second). The QRS interval
has no lower limit that indicates abnormality

6. Amplitude of QRS complex

There is no arbitrary upper limit for normal

voltage of the QRS complex. An abnormally low
QRS complex when the amplitude is no more than
0.5 mV in any limb leads and no more than 1.0 mV
in any of the precordial leads
Abnormal QRS interval

0.19 s
7. The axis of QRS complex
• Normal axis: between –30 degrees and +90
degrees
• Right axis deviation (RAD): between +90
degrees and ± 180 degrees
• Left axis deviation (LAD): between –30
degrees and –120 degrees
Right axis deviation (RAD)
Left axis deviation (LAD)
Morphology of the ST
segment
1. The ST segment represents the period during
which the ventricular myocardium remains in an
activated or depolarized state
2. ST segment normally located at the same
horizontal level with the PR segment
3. Normal variations:
• Slight upsloping, downsloping, or horizontal
depresion
• Early repolarization: displacement of ST
segment by as much as 0.1 mV in the direction of
the ensuing T wave
4. ST segment may be altered when there is
prolonged QRS complex
Normal ST segment
Normal ST-segment deviation
Morphology of the T and

U waves
 The T wave

• The T waves are positively directed in all leads

except aVR (negative) and V1 (biphasic)

• T waves do not normally exceed 0.5 mV in any limb

lead or 1.5 mV in any precordial lead

The U wave

U wave is either absent or present as a small wave

following the T wave and is usually most prominent in
leads V1 and V2. Increased prominence of the U wave
indicates the possibility of hypokalemia
The QTc interval
1. The QT interval measures the duration of electrical
activation and recovery of the ventricular
myocardium

2. The QT interval decreases as the heart rate

increases and therefore should be corrected for
cardiac rate (QTc interval)

3. QTc= QT/RR interval (in seconds)

The upper limit of QTc is 0.46 second (slightly
longer in in females)

4. QT interval varies among different leads. The

longest QT interval measured in multiple leads
should therefore be considered the true QT interval