ECG BASICS

DR. ATEEB MAHMOOD KHAN

FMO at Cardiac Imaging Dept AKUH
MBBS, FCPS (CARDIOLOGY)
DIPLOMATE CERTIFICATION IN ECHO BOARDS
 What is grammar ?
As defined by Oxford advanced learner dictionary grammar is “A particular theory that is
intended to explain the rules in language”.

One can learn mother tongue without learning grammar.

However one cannot teach his mother tongue without learning grammar.

In my experience our residents and paramedics learn cardiology as their mother tongue.

They learn by cramming clinical features , ECG and Echocardiography findings, without
reasoning and concepts.

They end up learning cardiology ( As their mother tongue) without learning the cardiology
grammar.
This is food for thought for the teachers and students.

I wish to emphasize the importance of learning and teaching the concepts in clinical
cardiology, which I consider as “ Cardiology grammar”.
 What is Cardiac Cycle?
To define this we need to understand changes which occurs when we switch on AC/fan ?

When we press switch on button an electric current is generated immediately

followed by mechanical activity, (rotation of fan & emission cold air from AC ) .
 Thus cardiac cycle is defined as

Repeated sequence of electro-mechanical changes in heart resulting in contraction

(systole) and active relaxation (Diastole).

So we have two types of activities in the heart.

Electrical Changes in the heart followed by Mechanical Changes .

The electrical changes in heart, represented by PQRST waves is recorded on a paper

know as Electrocardiogram, by an instrument called Electrocardiograph.

4
 From
Guyton and Hall Textbook of
Medical Physiology 12th edition
Conducting system of the heart
It consists of sinoatrial (S-A node), atrioventricular (A-V)
node and conducting fibers.

SA and AV nodes are located in right atrium(RA).

Normal rhythmical impulses are generated in S-A node.

Sinus nodal is connected directly with atrial muscle fibers

& two types of conducting pathways

Internodal (Three ) pathways connecting SA & AV nodes

From & one interatrial band connect RA with LA (left atrium).
[Link]
content/uploads/sites/1940/2017/05/29213842/hjbdduuk
[Link]
In this way, the action potential spreads through the
entire atrial muscle mass & the A-V node.

AV node is connected with main AV bundle (Bundle of

HIS) which divides into right and left bundle branches .

Two bundle branches divides terminally into fine fast

conducting fibers , purkinje fibers.

Thus His bundle ,bundle branches and purkinje fibers

transmits cardiac impulse to both ventricles.
 From.
[Link]
physiology/the-heart-conduction-system

Note that bundle of His divides into two large branches right and left bundle.

Left bundle is larger & and further divides into left anterior branch (Fascicle ) and Left posterior fascicle)

Thus ventricles have trifascicular conduction.

Morphology ( Shape ) of the ECG waves.
 A B C
Three blind persons visited zoo.

They got very different impressions about the

shape of elephant .

One observer (A)touched the back (Tail) of the

elephant.

Observer( B ) felt the body.

Observer (C )felt the front (trunk).

Modified from
The Only EKG Book You'll Ever Need,
If you wanted the correct description of the shape 5th Edition Malcolm s. Thaler
of elephant whom would you ask ?
All three.
ECG machine generate waves of muliple shapes and magnitude

Thus multiple ECG leads are required for orientation of multiple electrical vectors generated in the heart.
 Morphology of the ECG waves.

The direction and the magnitude of vector of depolarization changes as it spreads through the
different heart chambers.

These change in the direction of depolarization waves, in atrium and ventricles are recorded as
P and QRS waves, respectively by the ECG by electrodes placed in different position on the
chest & limbs.

As the multiple electrodes are placed is different location the shape and amplitude of the
waves (PQRS ) generated in leads vary.
 From
[Link]
[Link]/images/ekg-basics

What is Electrocardiogram ( ECG ) ?

When an electric impulse passes through the heart, electrical current spreads out into the
adjacent tissues surrounding the heart & on to skin surface.

If electrodes are placed on the skin on two opposite sides of the heart, it will collect electrical
activity generated by the vector (Dipole).

This is processed and recorded in on ECG paper in different waves wave forms is known as an
electrocardiogram ( ECG ).

Normal ECG tracings consist of waveform generated from different chambers of the heart
during each heart beat.

The normal ECG(see Fig.) These waveforms are labeled P, Q, R, S, T and U.

 Electrocardiogram (ECG) waves , segments and intervals.

ECG waves (PQRST & U) are positive (upward )or negative (Downward ) deflections long the Y
axis.

Segments are horizontal lines in the ECG along the X axis without intervening waves.

Intervals are horizontal lines along the X axis with one or more ECG waves .
 Total number of waves , segments and intervals of ECG.
Four waves .
P , QRS, T and u waves.
Four segments and intervals .
(Two segments and two intervals).
Intervals are horizontal lines in the ECG with one or more ECG waves.
Segments are horizontal lines in the ECG without waves.

PR interval and QT interval.

PR and ST segments.

By Derivative: RehuaOriginal: Hank van Helvete - This file was

derived from: EKG [Link], CC BY-SA 3.0,
[Link]
 Generation of ECG waves.
Each cardiac cycle is initiated by spontaneous depolarization of the sinus node (Located in right atrium).

This results in mechanical contraction and relaxation not recorded in ECG.

Atrial depolarization is recorded as P wave . Atrial repolarization is not commonly recorded in the ECG.

The first part of the P wave reflects right atrial(RA) activity; the second part reflects left atrial (LA) activity.

There is a brief pause after P wave as the electrical current cross AV node.(Due to slow conduction)

The wave of depolarization then spreads along the ventricular conducting system (His bundle, bundle
branches, and Purkinje fibers) and out into the ventricular myocardium.

Ventricular depolarization is recorded as QRS.

Ventricular repolarization is recorded as T wave

From
[Link] Modified from
electrodes-systems-limb-chest-precordial/ The Only EKG Book You'll Ever Need,
5th Edition Malcolm s. Thaler
 QS

Is this Q or S ?

This is QR

QS

[Link]
From
The Only EKG Book You'll Ever Need,
5th Edition Malcolm s. Thaler
This is R
QS
The QRS is wave complex of three waves (some times mentioned as QRS Interval)
It represents the time interval of ventricular depolarization.

A normal QRS interval, representing the duration of the QRS complex, is 60 to 100 m Sec.

Q wave is first downward deflection before R wave.

R wave is upward deflection .
S wave is downward deflection after R wave.
Single downward defection in ECG with no R wave is called QS wave .
 ECG intervals.
The PR interval measures the time from the start of atrial depolarization to the start of
ventricular depolarization (QRS).

QT interval. Measure the tme for both ventricular depolarization and repolarization .
It roughly estimates the duration of an average total ventricular action potential.
It therefore includes all of the electrical events that take place in the ventricles.

The QRS complex (In some books mentioned as interval) measures the time of ventricular
depolarization.

By Created by Agateller (Anthony Atkielski),

converted to svg by atom.
[Link], Public Domain,
[Link]
d=1560893
From
[Link]
 From
[Link]

The J point is a point in time marking the end of the QRS and the onset of the ST segment .

Thus it is junction of QRS with ST segment.

 U

From
The Only EKG Book You'll Ever Need,
5th Edition Malcolm s. Thaler

From
[Link]
PR interval in the ECG represents conduction time from the
SA node up to end of HIS bundle.
Conduction time from SA node up to AV node = 30 msec. Atrium.
+
Conduction time from AV node up to main AV (His ) bundle =
90 msec. ( HIS bundle)

+
Conduction time across bundle of His up to its division into
left and right bundle = 30 msec. Ventricle .

PR interval time in ECG is 30 + 90 + 40 = 160 msec.

QRS interval in the ECG represents conduction time from
division of the bundle of His up to epicardial surface of
ventricle From
Guyton and Hall Textbook of Medical Physiology 12th edition

Time from bundle branches to end of Purkinje fibers

(endocardial muscle mass ) =30msec.
+
Time interval from endocardial surface to the epicardial
surface. =30 msec.

Normal QRS duration is 60 to 100 mse.

These time intervals have a range ,those mentioned above

are approximatel values.
 Bipolar limb leads connections.
Lead I Lead II Lead III

The above illustration shows Leads I, II, and III, their placement & the electrical charges of their electrodes.

They are summarized as follows:

Lead I: Right arm-negative, Left arm-positive (Positive end is at +zero degree ).
Records electrical differences (voltage )between the left and right arm electrodes.

Lead II: Right arm-negative, Left leg-positive( Positive end is at +60 degree).
Records electrical difference (voltage ) between the left leg and right arm electrodes.

Lead III: Left arm-negative, Left leg-positive ( Positive end is at +120 degree).
Records electrical differences (voltage ) between the left leg and left arm electrode

Right leg doesn't come up in ECG readings & is considered as a grounding lead that helps minimize ECG
artifact.
Modified from
[Link]
Chapter V The 12-Lead EKG
 Electrical connection for recording augmented limb leads

From
Goldberger Al: clinical electrocardiography , A simplified approach 7th ed. St. Louis ,CVMosby.2006 CHAPTER 13ElectrocardiographyDavid M. Mirvis and Ary [Link].
[Link]

Augmented Unipolar Limb Leads.

In this type of recording, two of the limbs are connected to the
negative terminal of the ECG (Has zero potential).

Third limb is connected to the positive terminal.

When the positive terminal is on the right arm,it is named as as the

aVR lead.

When on the positive electrode is on the left arm, it is named as

aVL lead.

When on the positive electrode is on the left leg, it is named as the Figure modified from
[Link]
aVF lead. Cardiovascular Physiology Concepts.
Prof. Richard E. Klabunde, Revised 12/6/16
 Augmented unipolar leads.
Orientation of the lead placement and direction of lead

aVR the positive electrode aVL the positive electrode aVF the positive electrode
is on the right shoulder. is on the left shoulder. is on the left foot.
At -150 * At – 30* At +90*

Note that the positive electrodes of aVR and aVL are located in the negative electric zone.
Modifed From
[Link]
Chapter V The 12-Lead EKG
 Superior

Superior half
(Negative electric zone - 0* to -180*

Right Left

inferior half
(Positive electric zone +0* to +180*

Modified from
[Link] Inferior
Six limb leads measure the electrical activity of the heart along the frontal plan.

In frontal plane patient is in anatomical position & facing you. Therefore patient’s left side is
on your right side.

The six limb leads measure a circle or 360 degrees around the heart.

This six fontal plane leads placed across the heart form the hex axial reference system.

Note that aVR and aVL has positive terminal in the superior (Negative zone) .
Chest or precordial leads
 The Chest Leads (or Precordial Leads).

The precordial (chest leads) leads each consist of a positive electrode strategically placed on
the chest of the patient.

The unipolar chest leads detect electrical impulses from the heart along the horizontal
(transvers ) plane of the heart.

This tracing gives a different view of the heart and allows detection of arrhythmias that may
not be detectable in the frontal plane angles.
 chest leads

They record the electrical activity of the heart in

transverse ( Horizontal )plan different positions on the
chest .

six positive electrodes, named V1 to V6, are placed on

front of the chest (precordium.)

Right

ECG tracing of chest leads

Figur from
[Link]
Cardiovascular Physiology Concepts.
Prof. Richard E. Klabunde, Revised 12/6/16
 *Polarity of horizontal (Cross sectional ) plan ECG leads
Posterior

P
R

A L

From
[Link]

Horizontal body plan consists of two axis . 1. Z (Anterior-posterior ) & 2. Y axis (Superior-inferior)

Six precordial leads (V1 to V6) measure electrical activity along the horizontal plan.

Front-back direction (Z axis).

Right-left direction. (X axis).

*Polarity of ECG leads means orientation of positive and negative ends of the ECG leads.
 Spatial orientation of the QRS Vectors with the six limb leads.
Records electrical activity in frontal plan. X axis (Right –left) & Y axis ( Superior – inferior).

Modified From
[Link] Mr Clarkson Abigail
 Spatial orientation of the QRS Vectors with the six chest leads.
Records electrical activity in horizontal plan. X axis (Right –left) & Z axis (Anterior –Posterior).
Posterior

Anterior
Modified From
[Link] Mr Clarkson Abigail
 *Summary of the electrical connection of leads used during ECG recording.

The standard ECG leads consists of 3 different sets of electrical connection.

“The bipolar leads I, II, and I11 are recorded via the stable Wilson central terminal (WCT).”

“The unipolar chest leads V1-V6 leads are recorded via the stable Wilson central terminal (WCT).”

“The unipolar limb leads aVR, aVL, and aVF leads recorded via the Goldberger central terminal ( GCT)” .

*Reference
Madias JE. On recording the unipolar ECG limb leads via the Wilson's vs the Goldberger's terminals: aVR, aVL, and aVF
revisited. Indian Pacing Electrophysiol J. 2008;8(4):292-297.
 Standard 12-lead ECG electrodes location.

As discussed 10 electrodes are required for recording 12 leads ECG.

Four in four limbs and six on the chest.

Location of limb leads are straight foreword, however chest lead electrode attachment site needs brief
description.

To locate the exact site of electrode placement we need to identify few land marks (surface anatomy) on
the front of thorax.

Sternal angle & arbitrary lines are important land marks for locating
the intercostal space & location of the electrode placement site.
 Modified from
Arbitrary lines on the anterior aspect of thorax Chapter 10 The Chest
[Link]

A, Topographic landmarks of the anterior

thorax. Thoracic cage landmarks.

Arbitrary lines on the lateral aspect of the body.

B, Landmarks on the lateral view.

Land marks ,intercostal space & arbitrary lines for location of six chest electrode placement.

From
[Link] by Dr Mike Cadogan,
Electrode locations of right
sided chest leads

From
[Link]
content/uploads/2016/01/[Link]

It can be simpler to leave V1 and V2 in their usual positions.

Transfer leads V3-6 to the right side of the chest (i.e. V3R to V6R) in the same positions as is in left sided
chest leads. V1R Left 4th intercostal space left sternal border.

V2R Right 4th intercostal space right sternal border.

V3R Right 4th intercostal space between V2 & V4 .

V4R Right 5TH intercostal space mid clavicular line.

V5R Right 5TH intercostal space anterior axillary line.

V6R Right 5TH intercostal space mid axillary line..

 Posterior chest leads.
Anterior chest leads V4 to V6 , In 12 lead
ECG are replaced by posterior leads.

Lead V4 cable is connected to V7.

Lead V5 cable to V8.

lead V6 cable is connected to V9.

Leads V7-9 are placed on the posterior

chest wall in the following positions:

V7 – Left posterior axillary line, in the same

horizontal plane as V6.

V8 – Tip of the left scapula, in the same

horizontal plane as V6.
From
V9 – Left paraspinal region, in the same [Link]
horizontal plane as V6.
ECG paper
ECG PAPER. ECG paper is marked with a grid of small and large squares.(Similar to graph paper)

The EKG paper records time sequences on the X axis (horizontal deflections).

It records voltage or amplitude of the electrical activity of the heart on Y axis (vertical axis ).

Y axis (vertical axis )

X axis (horizontal axis) .

From
[Link]
 Horizontal lines (X axis)
The horizontal lines measure time intervals and
heart rate.

The ECG paper speed is normally set at 25

mm/sec but can be increased to ≥50 mm /sec.

ECG paper Key

Horizontal (X ) axis.( If paper speed is 25mm/sec).

Thin Lines= 1 mm intervals or 0.04 sec (40 m sec.)

Thick lines= 5 mm intervals or 0 .2sec (200 m sec.)

From
[Link]
 Vertical lines (Y axis).
Vertical lines measure the amplitude (height or depth ) of the ECG waves.

The amplitude of ECG waves is measured from the baseline ( isoelectric line) to the peak (of upward
deflection (positive wave ) or nadir of the downward deflection (Negative wave).

In Standard setting one mV deflection corresponds to 10mm thus one mm is equal to 0.1mV.

This voltage setting can be increased to one mV =20mm or reduced to one mV= 5mm if the ECG complexes
recorded are very low or high respectively.

ECG paper Key

Vertical (Y) axis.( Normal standardization ).

10 mm = 1 mV (I mm = 0.1 mV).

From
[Link]
 ECG is recorded on a graphic paper at different speed .
Following recording illustrates important measurements of ECG tracing.

Time (Running velocity) is displayed on x axis , and amplitude (Voltage) is displayed on Y axis.

Guess what is the paper running speed ?

From
[Link]

by Dr Mike Cadogan,

Paper(running) speed is 25mm/ sec.

1mm (small square) = 0.04 sec (40ms) . Why ?
5mm (large square) = 0.2 sec (200ms)
Why is 1 mm(on horizontal axis ) = 40 m sec if ECG is recorded at speed of 25 mm/sec. ?

From
[Link]

by Dr Mike Cadogan,

Explanation of why is 1 mm = 40 msec. at paper speed of 25 mm /sec.

Speed of 25mm/sec means 25 mm is = (one second ) or 1000 msec.

So 25 mm = 1000 msec.
Thus
1mm = 1000 ÷ 25 = 40m sec.
Why is 1 mm(on horizontal axis ) = 20 m sec if ECG is recorded at speed of 50 mm/sec. ?

Modifed From
[Link]
by Dr Mike Cadogan,

Explanation of why is 1 mm = 20 msec. at paper speed of 50 mm /sec.

Speed of 50mm/sec means 50 mm is = (one second ) or 1000 msec.

So 50 mm = 1000 msec.

Thus 1mm = 1000 ÷ 50 = 20m sec.

 Impact of recording ECG at different speeds .
Modifed From
[Link]

by Dr Mike Cadogan,

What will be effect of 50mm speed on width of P and QRS width ECG intervals and & why ?
Explanation of why the interval, segments and width of waves doubles at speed of 50mm/sec.?
P wave width in 25mm strip is 2.5 mm (2.5X 40)= 100 m sec
In same ECG at 50mm strip P wave width 5 mm = 200 msec (Doubles).
This is because in 25mm speed 1mm =40 m secs but at 50 mm speed 1mm= 20 m sec.
Therefore at speed of 25mm/sec, 1mm (40 m sec ) = 2mm (20 x 2= 40 m sec.)at speed of 50 mm
Why use 50 mm/second recording ?

Modified From
[Link]

by Dr Mike Cadogan,

Reveal flutter waves in 2:1 block.

Red arrows (P or F waves)

 Estimation of heart rate ( P or QRS ) rate ?
At paper speed of 25 mm/sec, one second of strip = 25 mm.
One minute of strip = 25x 60 = 1500 mm(small square).

Estimation of QRS rate in a subject with regular heart rate. -------10 mm ------

Count the number of small square between to two QRS .

In this example it is 10 (small squares) mm as shown in the fig.

Modifed From
In this ECG ten mm =one beat (QRS). [Link]
by Dr Mike Cadogan,
1
So one mm QRS rate = 10 X (QRS),beats
1
So 1500 mm QRS rate = X 1500 (QRS)
10
1 x1500=150 beats/min
In 1500 mm or one minute we will have =
10 -------10 mm ------
In this complex there are 15 mm between QRS therefore QRS
rate will be 1500 ÷ 100 = 100 beats /min.
Alternate less preferable method of estimating QRS rate in a subject with regular heart rate.

At a paper speed of 25 mm/second one second of strip = 25 mm (small squares) or five large squares.

One minute of strip = 25x 60 = 1500 mm(small square) = 300 large squares

The number of large square in one beat I e between to two QRS in this ECG =4

In this ECG 4 large square =one beat (QRS).

One large square = 1÷4 beats (QRS).

So in 300 large square( one minute) we have = 300 ÷ 4 = 75 beats/min.

Modifed From
[Link]

by Dr Mike Cadogan,

*This is less preferable method

 Two methods of calculating heart rate

Using 1500 divided by number of

small squares between R-R.

Modifed From
[Link]

by Dr Mike Cadogan,

Using 300 divided by number of

large squares between R-R.

Example of 1500 (small squares) versus 300 (large square) method.

Which one is preferable , justify ?

 3rd Method of estimation of heart rate .
Modifed From
[Link]
by Dr Mike Cadogan,

The above 10 second rhythm strip has 9 QRS beats

If rhythms is irregular we can estimate average heart ( QRS) rate from 10 second strip.

At a paper speed of 25 mm/second one second of strip = 25 mm (small squares).

Ten seconds strip = 250 mm (small squares) .

As one large square consists of 5 small squares therefore 250 small squares = 50 large squares.

Therefore Ten seconds strip = 50 large squares.

The number of QRS complexes (count R waves) on the rhythm strip gives the average rate over a ten-
second period.

This is multiplied by 6 (10 seconds x 6 = 1 minute) to give the average beats per minute.
 ECG derived estimation of heart rate using three techniques at paper speed 25 mm /sec

Above 10 second strip has 9 beats

Modifed From
[Link]
by Dr Mike Cadogan,

Calculate atrial( P ) &ventricular(QRS) rates separately if their rates are not same e.g. complete heart block)
Estimation of heart beat , dividing 1500 by number of small squares .
Number of Small Rate Per
Square (mm) Minute
30 50
29 52
28 54
27 56
26 58
25 60
24 63
23 65
22 68
21 72
20 75
19 79
18 84
17 88
16 94
15 100
14 107
13 115
12 125
11 136
10 150
9 167
8 188
7 214
6 250
5 300
From
[Link]
ECG Axis
 What is mean axis of a vectors ?

Foot ball match.

From
The Only EKG Book You'll Ever Need,
5th Edition Malcolm s. Thaler

B
A.. The directions of each of kick in different directions during the foot ball game , represents
small vectors of directions of motion of the ball .(Figure A)

B. Single vector represents the average direction of and magnitude ( distance) of these kicks.

This is mean axis of direction of the movement (vector ) of the ball.(Figure B).
 What is axis of ECG waves (Vector) ?
This refers to directions of the vectors of depolarization or repolarization.

During depolarization of atria or ventricles electrical waves (vectors ) are generated .

It spreads across the muscle mass generating multiple small vectors , having different directions
and magnitude(force).

What is mean electrical axis ?

Mean electrical axis is the over all (average) direction of vectors of electrical conduction.

By convention the electrical axis is referred to QRS axis ( ventricular depolarization ).

However mean electrical axis of P wave ( atrial depolarization ) and T wave (ventricular
repolarization ) can be also be determined with same method.
 Mean electrical axis vectors of P and QRS vectors.

In normal heart the mean axis of P waves(atrial depolarization) & QRS (ventricular
depolarization ) vectors is directed inferiorly to the left at an angle of +0 - * + 90*.

Most often around an angle 40 * to 60 * ,Why ?

Atrial depolarization starts from Right atrium (SA nodes) located superiorly and right corner
therefore normal mean axis of the P wave vector is directed inferiorly and towards left.

Atria are located superior to ventricles therefore direction of ventricular depolarization (QRS) is
directed inferiorly.

Long axis of heart is placed at an angle of 45* to the long axis of body plan (sagittal plan) ,
moreover thicker LV generates a stronger depolarizing current than that generated by the less
bulky RV.

Thus normal mean axis of QRS points downward and to the left.

This is termed mean electrical axis of P wave and QRS.

 Keep in mind the rules of electrical conduction across myocardial cell.

A wave of depolarization travelling toward a positive electrode results in a positive (upward )

deflection in the ECG tracing.

A wave of depolarization travelling away from a positive electrode results in a negative

(downward ) deflection.

A wave of repolarization travelling toward a positive electrode results in a negative deflection.

A wave of repolarization travelling away from a positive electrode results in a positive

deflection.

A wave of depolarization or repolarization travelling perpendicular (At 90* ) to an electrode axis

results no net (Isoelectric ) deflection.

From
[Link]
Cardiovascular Physiology Concepts.
Prof. Richard E. Klabunde, Revised 12/6/16
 Methods of estimating mean QRS axis .

There are many methods of estimating mean QRS axis. One simple method is described.

First step is to look at limb Lead I and aVF.

Examine the QRS complex in each lead & determine if the main QRS is Positive , Negative or
Isoelectric (Eqviphasic).

Modifed From
[Link]
by Dr Mike Cadogan,
 look at LEAD I and LEAD aVF.
A positive QRS in Lead I puts the axis in roughly directed toward the positive end of lead I.

A positive QRS in Lead aVF similarly directed toward the positive end of lead aVF.

Combining both coloured areas – the quadrant of overlap determines the axis.

Thus If Lead I and aVF are both positive, the axis is between 0° and +90° (i.e. normal axis)

Modifed From
[Link]
by Dr Mike Cadogan,
Normal Axis = QRS axis between -30° and +90°.

Left Axis Deviation ( LAD)= QRS axis less than -30°(-31 to -90).

Right Axis Deviation (RAD) = QRS axis greater than +90°.

Extreme Axis Deviation = QRS axis between -90° and 180° ( “Northwest Axis”).

Modifed From
[Link]
by Dr Mike Cadogan,

LAD= Left axis deviation.

RAD = Right axis deviation
Summary of mean QRS direction and mean QRS axis.

Modifed From
[Link]
by Dr Mike Cadogan,
 Summary of the vectors of Ventricular depolarization generating QRS in lead 11.
Vector Location Direction ECG waves & voltage
1 Mid basal septum From left to right (+150*). Small Q

2 L V apex Left and inferiorly (+60*) Tall R

3 LV free wall (anterolateral) Left & *anteriorly ( - 10* -0 *) Small R

4 Inferior basal part of LV. Posterior and superior ( -80*) Small Q

Vector 1 Vector 2 *Vector 3 Vector 4

Modified from
[Link]
Cardiovascular Physiology Concepts.
Prof. Richard E. Klabunde, Revised 12/6/16

*Vector 3 spreads from the endocardial to the epicardial surface anteriorly and left wards.