Electrocardiogram (ECG)

Electrocardiogram (ECG, sometimes called EKG) is a reflection of the electrical

activity of the heart. ECG is the most commonly used biomedical signal in clinical
diagnostics of the heart.

The word “electrocardiogram” is a combination of three words: electro, meaning

electric signal; cardio, which translates into heart; and gram, which stands for
recording. The recording of the electric activity of the heart is called ECG.

The heart

The heart is the structure comprised of cardiac muscles that are responsible for
circulating blood through the body. The heart has four major functions: collecting the
blood that needs to be refined from all parts of the body (through veins), pumping this
collected blood to the lungs, collecting the refined blood from the lungs, and pumping
the refined blood back to all parts of the body. The heart has four chambers: two atria
and two ventricles.

The heart chambers continuously expands and contracts to allow the process of
collecting and pumping the blood, respectively.

The functions of the four chambers of the heart are shown in the following table.
Chamber Relax Contract
 Right Atrium Receive the Pump the oxygenpoor
oxygenpoor blood blood to the
from the body
right ventricle

Right Ventricle Receive the Pump the oxygenpoor

oxygenpoor blood blood to the
from the lungs to be refined
right atrium
Left Atrium Receive the refined Pump the refined
blood from the lungs blood to the left
ventricle.

Left Ventricle Receive the refined Pump the refined

blood from the left blood to the body
atrium

The repetitive contraction and expansion of the heart muscle is a result of local electric
potential differences, which can be measured on the skin using electronic recording
equipment. This group of signals, called ECG, records the strength and timing of the
electrical activity in the heart, and constitutes the most informative clinical signal
commonly used in the diagnosis of the cardiovascular system.

The ECG represents the repetitive electric depolarization and repolarization pattern
of the heart muscle. The waveform of ECG is recorded on a graph that shows each
phase of the electrical signal as it travels through the heart.

A typical healthy ECG signal is shown in the following figure.

Characteristics of ECG

The schematic form of one period of the ECG is illustrated in the figure below.

The ECG is characterized by five peaks (waves), represented by the letters P, Q, R,

S, T, and sometimes followed by a sixth peak, the U wave. The P wave is the result
of the depolarization of the atrium, while the remaining waves are caused by the
ventricle.
Usually, the combination of Q, R, and S peaks are referred to QRS complex.

Origin of ECG
The electrical signal begins in the sinoatrial node (SA) which is located in the right
atrium and travels to the right and left atria, causing them to contract and pump blood
into the ventricles. This electrical signal is recorded as the P wave on the ECG. The
PR Interval is the time, in seconds, from the beginning of the P wave to the beginning
of the QRS complex.

The electrical signal passes from the atria to the ventricles through the atrioventricular
(AV) node. The signal slows down as it passes through this node, allowing the
ventricles to fill with blood. This slowing signal appears as a flat line on the ECG
between the end of the P wave and the beginning of the Q wave. The PR segment
represents the electrical conduction through the atria and the delay of the electrical
impulse in the atrioventricular node.

After the signal leaves the AV node it travels along a pathway called the bundle of
His and into the right and left bundle branches. The signal travels across the heart’s
ventricles causing them to contract, pumping blood to the lungs and the body. This
signal is recorded as the QRS waves on the ECG. Because these waves occur in rapid
succession they are usually considered together as the QRS complex.

The ventricles then recover to their normal electrical state, shown as the T wave. The
muscles relax and stop contracting, allowing the atria to fill with blood and the entire
process repeats with each heartbeat. The ST segment connects the QRS complex and
the T wave and represents the beginning of the electrical recovery of the ventricles.

The QT interval represents the time during which the ventricles are stimulated and
recover after the stimulation. This interval shortens at a faster heart rate and lengthens
at a slower heart rate.

ECG recording: First attempt

Electrocardiography made its introduction through the pioneering efforts of the Dutch
scientist Willem Einthoven in 1903. He used a galvanometer to design a way to record
the action potentials. He also introduced the markers P, Q, R, S, and T on the standard
ECG. In 1924, Einthoven received the Nobel Prize for the invention of
electrocardiography and its development.

The initial ECGs were recorded directly on paper and, in fact, still are in many clinical
cardiac electrophysiology laboratories. The galvanometer was directly coupled to an
ink pen. This way, a voltage leading to a deflection of the galvanometer would move
or direct the pen over the paper. Each individual electrode had its own galvanometer
and separate ink pen. This method still stands as the gold standard for analog
recordings. However, nowadays, the electrodes are connected to amplifiers and filters
for the amplification of the signal and noise elimination.

The following figure depicts the initial procedure adopted by Willem Einthoven to
record the ECG signal from the surface of the skin.

ECG electrodes configuration for clinical recordings

The electrical activity going through the heart (ECG) can be measured by attaching
external electrodes to the skin. Commonly, 10 electrodes attached to the body are used
to form 12 ECG leads, with each lead measuring a specific electrical potential
difference. This method is used in hospitals to obtain a clean ECG signal which can
be used in diagnosis of most heart diseases.

The 10 electrodes in a 12-lead ECG are: RA, LA, RL, LL, V1, V2, V3, V4, V5, and V6.

The 12 leads are formed as a type of combination of these 10 electrodes.

The positions of the 10 electrodes are shown in the following figures.