1. Ulkumen Rodoplu, MD EuSEM ELECTROCARDIOGRAPHY

2. Plan A Normal ECG Basic ECG Waveform Initiation of Spread of Electrical Activation in the Hearth The Magnitude and Direction of the Activation Process Activation Vectors

3. Introduction - Essential tool in the investigation of heart disease. - No cardiological assessment is complete without a 12-lead ECG. - One hundred million ECGs are recorded worldwide each year.

4. History 19th century. The heart generated electricity. 19th century Augustus Waller, working in St Mary's Hospital in London: The first systematical approach about the heart from an electrical point-of-view. Augustus WallerSt Mary's Hospital London Willem Einthoven, working in Leiden, The Netherlands, invented the string galvanometer, which was much more precise than the capillary galvanometer that Waller used. Willem EinthovenLeidenThe Netherlandsgalvanometercapillary Einthoven assigned the letters P, Q, R, S and T to the various deflections, and described the electrocardiographic features of a number of cardiovascular disorders. He was awarded 1924 Nobel Prize for Physiology and Medicine for his discovery.1924Nobel Prize for Physiology and Medicine

5. Initiation and Spread of Electrical Activation in the Heart In normal circumstances the whole process begins in the sino-atrial node.

6. Initiation and Spread of Electrical Activation in the Heart SA Node normally initiates activation of the atrial myocardium AV Node transmits activation received from the SA Node to the common bundle HIS Bundle forms the electrical connection between the atria and the ventricles

7. Initiation and Spread of Electrical Activation in the Heart The right and left bundle branches run below the endocardial surfaces of their respective ventricles The Purkinje network spreads over the endocardial surfaces of the ventricles

8. The Basic ECG Waveform P wave - spread of electrical activation through the atrial myocardium. QRS Complex – spread of electrical activation through ventricular myocardium. T wave – electrical recovery of the ventricular myocardium.

9. Electrical Activity & ECG

10. P Wave < 0.10 sec. wide < 2.5 mm. amplitude (+)……DI, II, aVF (+) (-)… aVL (-)… aVR VI, biphasic or (-)

11. PR interval 0.12 – 0.20 sec

12. QRS Depolarisation of ventricles < 0.10 sec. wide

13. T Wave Repolarisation of ventricles 0.12-0.25 sec. wide (+)…DI, II, V2-6 (+) (-)…aVL, aVF (-)….aVR

14. Calculation of Rate

15. Activation Vectors - A vector is simply something which has magnitude and direction. - Direction in which the arrow points represents the direction of the vector. - Length of the arrow represents the magnitude of the vector. - The apparent magnitude of the activation wave will depend on the direction from which it is sensed.

16. Polarisation and Depolarisation - Activation is actually the process of depolarisation and the spontaneous spread of this process over the myocardial cells. - Resting, healthy mycardial cells are polarised. - The surface membrane of each cell has an accumulation of charges – positive ones on the outside and an equal number of negative ones on the inside.

17. The QRS Complex - The central oblong is the myocardial strip. - The arrow shows the depolarisation vector in magnitude and in direction. - The deflection recorded by each lead is shown at the side of that lead.

18. A Normal 12 - Lead Electrocardiogram

19. ECG Derivations Bipolar…DI, DII,DIII Unipolar…aVR, aVL, aVF Precordial….V1….V6

20. Precordial Electrodes

21. Einthoven Triangle

22. A Normal Vectorcardiogram

23. Electrical Axis

24. Electrical Axis-Triaxial Method

25. Electrical Axis- Hexaxial Method

26. Electrical Axis-Practical Method I,II,III,aVF.. QRS(+).... Normal I…QRS(-), aVR…QRS(+)…RAD II,III,aVF.. QRS(-)....30º LAD

27. Normal ECG Leads

28. Normal Sinus Rhytm

29. Sinus Tachycardia

30. Sinus Bradycardia

31. Sinus Arrhytmia

32. Atrial Escape Beat

33. Nodal Escape Beats

34. Nodal Rhythm in Complete AV Block

35. Atrial Tachycardia

36. Supraventricular Tachycardia

37. Atrial Flutter – atrial rate 300

38. Atrial Flutter – 2:1 Conduction, Atrial rate 300

39. Ventricular Premature Contractions

40. Multiform VPBs

41. Ventricular Couplets

42. Ventricular Flutter

43. Ventricular Fibrilation

44. First degree AV Block

45. Second degree AV Block Wenckebach or Mobitz Type I

46. Second degree AV Block Mobitz Type II