University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr.
Rafid Doulab
ELECTROCARDIOGRAPHY
The heart is a three-dimensional organ. It takes around a third of a second for the various
regions to activate fully, during which time there are waves of electrical activity racing
through its internal structures. The ECG captures a series of one-dimensional snapshots of
these electrical events to create a remarkably detailed picture about their timing, direction,
and the mass of tissues involved.
A. Theory
An ECG records extracellular potentials using electrodes adhered to the body surface. The
potentials are generated by current flowing through surrounding tissues from depolarized
areas of the heart to polarized regions (electrical dipole) as shown in Figure 1.
Current intensity is directly proportional to size of the dipole. Three ECG electrodes are
arranged in a triangle (Einthoven triangle) around the heart and connected to an ECG
recorder. The recorder systematically compares voltage differences between pairs of
electrodes and generates a moving paper record. These comparisons, which are facilitated
by rapid switching within the ECG recorder, are known as ECG leads (Figure 2). There
are two general types of leads: limb leads and precordial leads.
Figure 1 Figure 2
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
1. Bipolar limb leads: There are three bipolar limb leads, which are created by comparing
voltage differences between each of the three ECG electrodes (Figure 2A). Lead I records
voltage differences between the right and left shoulders, lead II compares the right shoulder
and the left foot, and lead III compares the left shoulder and left foot. By convention, the
left shoulder is designated the positive pole of lead I, whereas the foot is designated the
positive pole of leads II and III.
2. Augmented limb leads: Three unipolar leads compare voltage differences between skin
electrodes and a common reference point (central terminal) that is held close to zero
potential (Figure 2B). Leads aVL, aVR, and aVF measure voltage differences between this
point and the left shoulder, right shoulder, and foot, respectively. The skin electrodes are
considered to be the positive pole in each case.
3. Precordial leads: Precordial or chest leads compare voltage differences between the
common reference point and six additional skin electrodes placed in a line directly above
the heart (V1 through V6).
B. Electrocardiograph
All ECG recordings are standardized so that their interpretation becomes a simple matter of
pattern recognition to a trained eye. By convention, when a wave of depolarization is moving
through the heart toward the positive pole of a lead, it causes an upward (positive) deflection
on the ECG recording. Movement toward the negative pole causes a downward (negative)
deflection. Depolarization of a large muscle mass generates a larger dipole than a smaller
mass, so it generates a larger deflection on the record.
C. Normal electrocardiogram
A typical ECG recording comprises fi ve waves, P through T, that correspond to the
sequential excitation and recovery of the different regions of the heart (Figure 3).
1. P wave: The myocardium rests between beats, and the ECG pen rests at the isoelectric
line. Excitation begins with the SA node, but the current that it generates is too small to
record at the body surface. The wave of depolarization then spreads across the atria,
registering as the P wave. When both atria are depolarized fully, the pen returns to baseline.
A normal P wave has a duration of 80–100 ms. 2. QRS complex: The P wave is followed
by a brief period of quiet during which the wave of excitation moves slowly through the AV
node and crosses from atria to ventricles via the bundle of His.
This progression does not register on the recording. Ventricular depolarization produces the
QRS complex. The three components reflect excitation of the intraventricular septum (Q
wave), the apex and the free walls (R wave), and finally the regions near the base (S wave).
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
The recording returns to baseline when the entire ventricular myocardium is depolarized,
roughly coinciding with phase 2 of the ventricular AP. The entire complex lasts 60–100 ms.
Figure 3
3. T wave: Ventricular repolarization registers on the ECG recording as the T wave. On rare
occasions, the T wave may be followed by a small U wave, thought to represent papillary
muscle repolarization.
The time intervals between the waves are also named and can provide important insights
into cardiac function (Table 1).
Table 1
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
D. Rhythms
The heart of a healthy individual at rest beats with a normal sinus rhythm of 60–100
beats/min. Some individuals have normal rates that fall below this range (sinus bradycardia),
whereas strenuous physical activity typically causes the normal rate to exceed 100 beats/min
(sinus tachycardia). The “sinus” prefi x to both rhythms indicates that the rate is established
by the SA node. Abnormal rhythms (dysrhythmias and arrhythmias) can originate from
virtually any part of the myocardium (Figure 4).
1. Atrial arrhythmias: Atrial fibrillation (AF) is an arrhythmia caused by one or more
extranodal atrial pacemakers that typically cycle at several hundred times per minute. AF is
relatively common, especially among older adults and in patients with heart failure. Loss of
atrial pump function reduces CO, and patients typically present with fatigue, dyspnea, and
lightheadedness as a result. The AV node acts as a filter that usually protects the ventricles
from arrhythmias of atrial origin. The node is re-excited by the chaotic electrical activity
running through the atria whenever it emerges from its refractory period so HR may be
irregular and tachycardic, but the QRS is normal because the wave of excitation is still
coordinated by the His–Purkinje system.
2. Atrioventricular block: Functional and anatomic defects in the AV node can delay or
interrupt transmission of signals to the ventricles, a condition known as AV nodal block.
Block occurs during the PR interval, because this is the time when the wave of excitation
propagates from atria to ventricles. AV block is generally described as being first, second,
or third degree, according to severity.
a. First degree: First-degree block is characterized by a lengthening of the PR interval (>0.2
s). It is usually benign and asymptomatic.
b. Second degree: Two types of second-degree block are recognized. Möbitz type I (also
known as Wenckebach block) describes a rhythm in which the PR interval lengthens
gradually until a complete block occurs, at which point the ventricles fail to excite, and the
ECG recording drops a QRS complex. Möbitz type II block is characterized by ECG
recordings in which the QRS complex is dropped with no prior warning. Type I is usually
benign. Type II may progress rapidly to third-degree block.
c. Third degree: Third-degree block is caused by a defect in the AV node or conduction
system that completely prevents electrical signals from reaching the ventricles. In absence
of guidance from the SA node, pacemakers located in the bundle of His or Purkinje network
often take over the responsibility for driving ventricular contraction. The ECG typically
shows a normal, regular P wave, and a QRS complex that may also be regular but temporally
disconnected from the sinus rhythm.
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
Figure 4
3. Ventricular dysrhythmias: Dysrhythmias can also have ventricular origins. Ectopic
ventricular rhythms originating in the contractile portions of the myocardium propagate via
gap junctions until the entire heart is involved. Because the wave of excitation spreads via
the myocardial equivalent of slow back streets rather than the Purkinje highway system, the
resulting QRS complexes are broad. The excitation sequence is abnormal also, so the QRS
complex is highly atypical. Occasional (<6/min) premature ventricular contractions (PVCs)
of ectopic origin are common and usually benign (Figure 4). Ectopic pacemakers have the
potential to pace the myocardium at high rates ( ̴ 300 beats/min), a rhythm known as
ventricular tachycardia (V-tach). The onset of V-tach is a grave event because pacing the
heart at such high rates disrupts pump function to the point where CO drops to zero. A
myocardium deprived of O2 supply quickly degenerates into ventricular fibrillation (V-fib)
and sudden cardiac death.
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
E. Mean electrical axis
The mean electrical axis (MEA) averages the many electrical vectors generated by the wave
of excitation as it moves through the heart. It provides a single value that indicates which
region of the heart dominates the electrical events (Figure 5). In a healthy individual, the
LV dominates because it contains the largest mass of tissue.
By convention, a circle is drawn around the heart in the plane of the limb leads, and the left
side taken to be at 0°, the right side to be at 180°, the feet to be at -90°, and the head to be
at -90°. In a normal, healthy individual, the MEA lies between -30° and +105°. If the MEA
is less than -30°, the left side of the heart must be contributing to the MEA to a greater extent
than normal. This is known as left axis deviation and is usually an indication of left
ventricular hypertrophy.
An MEA of greater than +105° (right axis deviation) indicates right ventricular hypertrophy.
Figure 5
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
Practical Application of ECG
Electrocardiogram Leads
As the heart undergoes depolarization and repolarization, electrical currents spread
throughout the body because the body acts as a volume conductor. The electrical currents
generated by the heart are commonly measured by an array of electrodes placed on the body
surface, and the resulting tracing is called an electrocardiogram (ECG, or EKG). By
convention, electrodes are placed on each arm and leg (standard and augmented limb leads),
and six electrodes are placed at defined locations on the chest (precordial leads). These
electrode leads are connected to a device that measures potential differences between
selected electrodes to produce the characteristic ECG tracings.
Some ECG leads are bipolar leads (e.g., standard limb leads) that use a single positive and
a single negative electrode between which electrical potentials are measured. Unipolar leads
(augmented leads and chest leads) have a single positive recording electrode and use a
combination of the other electrodes to serve as a composite negative electrode. Normally,
when an ECG is recorded, all leads are recorded simultaneously, giving rise to what is called
a 12-lead ECG.
Electrocardiogram Standard Limb Leads (Bipolar)
ECG Einthoven triangle Bipolar recordings use standard limb lead configurations depicted
in the figure. By convention, lead I has the positive electrode on the left arm, and the
negative electrode on the right arm, and therefore measures the potential difference
between the two arms. In this and the other two limb leads, an electrode on the right leg
serves as a reference electrode for recording. In the lead II configuration, the positive
electrode is on the left leg and the negative electrode is on the right arm. Lead III has a
positive electrode on the left leg and a negative electrode on the left arm. These three
bipolar leads roughly form an equilateral triangle (with the heart at the center) that is
called Einthoven's triangle in honor of Willem Einthoven, who developed the
electrocardiogram in the early 1900s. Whether the limb leads are attached to the end of the
limb (wrists and ankles) or at the origin of the limb (shoulder or upper thigh) makes little
difference in the recording because the limbs act like a long wire conductor originating
from a point on the trunk of the body.
Based upon universally accepted ECG rules, a wave of depolarization heading toward the
left arm gives a positive deflection in lead I because the positive electrode is on the left arm.
Maximal positive ECG deflection occurs in lead I when a wave of depolarization travels
parallel to the axis from the right to left arm. If a wave of depolarization heads away from
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
the left arm, the deflection is negative. Furthermore, by these rules, a wave of repolarization
moving away from the left arm is recorded as a positive deflection. Similar statements can
be made for leads II and III, in which the positive electrode is located on the left leg. For
example, a wave of depolarization traveling toward the left leg produces a positive
deflection in both leads II and III because the positive electrode for both leads is on the left
leg. A maximal positive deflection is recorded in lead II when the depolarization wave
travels parallel to the axis between the right arm and left leg. Similarly, a maximal positive
deflection is obtained in lead III when the depolarization wave travels parallel to the axis
between the left arm and left leg.
Electrocardiogram Chest Leads (Unipolar)
ECG chest leadsBesides the three standard limb leads and the three augmented limb leads
that view the electrical activity of the heart from the frontal plane, there are six precordial,
unipolar chest leads. This configuration places six positive electrodes on the surface of the
chest over different regions of the heart to record electrical activity in a plane
perpendicular to the frontal plane (see figure at right). These six leads are named V1 – V6.
The rules of interpretation are the same as for the limb leads. For example, a wave of
depolarization traveling toward a particular electrode on the chest surface will elicit a
positive deflection.
The chest leads overlie the following ventricular regions:
Leads Ventricular Region
V1-V2 anteroseptal
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
V3-V4 anteroapical
V5-V6 anterolateral
This placement of chest leads produces the following normal ECG tracings:
electrocardiogram chest lead tracingsBecause initial ventricular depolarization is from left
to right across the septum, there is an initial R-wave in V1 followed by an S-wave as the
anterior and lateral walls of the left ventricle depolarize. Leads V5 and V6 have a large net
positive QRS because these leads overlie the anterolateral wall of the left ventricle, which
has a large muscle mass undergoing depolarization. Tracings from leads V5 and V6 are
almost opposite in polarity from V1 because they are viewing opposite sides of the heart.
Leads V2-V4 are intermediate owing to their electrode placement.
Electrocardiogram Augmented Limb Leads (Unipolar)
ECG augmented lead axisBesides the three bipolar limb leads, there are three augmented
unipolar limb leads. These are termed unipolar leads because there is a single positive
electrode that is referenced against a combination of the other limb electrodes. The
positive electrodes for these augmented leads are on the left arm (aVL), the right arm
(aVR), and the left leg (aVF). These are the same electrode locations are used for leads I,
II and III. (The ECG recorder does the actual switching and rearranging of the electrode
designations). The three augmented leads are depicted as shown by the axial reference
system. Lead aVL is at -30° relative to the lead I axis; aVR is at -150° and aVF is at +90°.
It is essential to learn which lead is associated with each axis.
University of Basrah – College of Pharmacy CVS 2ed lecture 2024-2025 Dr. Rafid Doulab
For a heart with a normal ECG and mean electrical axis of +60°, the augmented leads will
appear as shown below:
ECG augmented lead tracings
ECG limb leads axisThe three augmented unipolar leads, coupled with the three standard
bipolar limb leads, comprise the six limb leads of the ECG, as shown in the figure. These
six leads record electrical activity along a single plane, termed the frontal plane relative to
the heart. Using the axial reference system and these six leads, one can define the direction
in the frontal plane of an electrical vector at any instant in time. If a wave of depolarization
is spreading from right-to-left along the 0° axis, then lead I will have the greatest positive
amplitude. Lead aVF will have the greatest positive deflection when the direction of the
electrical vector for depolarization is directed downwards (+90°). If a wave of
depolarization is moving from left-to-right at +150°, then aVL will have the greatest
negative deflection according to the rules for ECG interpretation.
