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The normal ECG

A typical ECG tracing of a normal heartbeat consists of a P wave, a QRS complex and a T wave. A small U wave is not normally visible.

Axis
The axis is the general direction of the electrical impulse through the heart. It is usually directed to the bottom left, although it can deviate to the right in very tall people and to the left in obesity. Extreme deviation is abnormal and indicates a bundle branch block, ventricular hypertrophy or (if to the right) pulmonary embolism. It also can diagnose dextrocardia or a reversal of the direction in which the heart faces, but this condition is very rare and often has already been diagnosed by something else(such as a chest x-ray).

P wave
The P wave is the electrical signature of the current that causes atrial contraction. Both the left and right atria contract simultaneously. Irregular or absent P waves may indicate arrhythmia. Its relationship to QRS complexes determines the presence of a heart block.

QRS
The QRS complex corresponds to the current that causes contraction of the left and right ventricles, which is much more forceful than that of the atria and involves more muscle mass, thus resulting in a greater ECG deflection.

The Q wave, when present, represents the small horizontal (left to right) current as the action potential travels through the interventricular septum. Very wide and deep Q waves do not have a septal origin, but indicate myocardial infarction.

The R and S waves indicate contraction of the myocardium. Abnormalities in the QRS complex may indicate bundle branch block (when wide), ventricular origin of tachycardia, ventricular hypertrophy or other ventricular abnormalities. The complexes are often small in pericarditis.

T wave
The T wave represents the repolarization of the ventricles. The QRS complex usually obscures the atrial repolarization wave so that it is not usually seen. Electrically, the cardiac muscle cells are like loaded springs. A small impulse sets them off, they depolarize and contract. Setting the spring up again is repolarization (more at action potential).

In most leads, the T wave is positive. Negative T waves can be signs of disease, although an inverted T wave is normal in V1 (and V2-3 in black people).

The ST segment connects the QRS complex and the T wave. It can be depressed in ischemia and elevated in myocardial infarction, and downslopes in digoxin use.

T wave abnormalities may indicate electrolyte disturbance, such as hyperkalemia.

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