Direction of depolarization
(vector) of the QRS complex
- The left ventricle is thicker so the
mean QRS vector is down and to the left.
(The origin of the vector is the AV node with the left ventricle being down
and to the left of this).
- The vector will point toward hypertrophy
(thickened wall) and away from the infarct (electrically dead area).
Axis nomenclature
Normal axis |
-30 to +90 degrees |
Left axis deviation |
-30 to -90 degrees |
Right axis deviation |
+90 to +/-180 degrees |
Indeterminate (extreme) axis deviation |
-90 to +/-180 degrees |
Since lead I and aVF are perpendicular
to each other, you can use those two leads to quickly determine axis.
Lead I runs from right to left across
a patient's body, positive at the left hand.
If the QRS in lead I is positive (mainly
above the baseline), the direction of depolarization will be in the
positive half (right half) of the circle above. You can make a diagram
and shade in the positive half of the circle.
Lead aVF runs from top to bottom across
a patient's body, positive at the feet.
If the QRS in lead aVF is positive (mainly
above the baseline), the direction of depolarization will be in the
positive half (lower half) of the circle above. You can make a diagram
and shade in the positive half of the circle:
To find the axis, overlap the two circles.
The common shaded area is the quadrant in which the axis lies.
In this
example, the axis lies in the normal quadrant, which on a patient,
points down and to the left.
You can repeat this process for any two
leads, but I and aVF are the classic places to look.
If you realize
that there are two leads to consider and a positive (+) or (-) orientation
for each lead, there would be four possible combinations.
Memorize the following
axis guidelines:
|
Lead
I
|
Lead
aVF
|
1. Normal
axis (0 to +90 degrees) |
Positive
|
Positive
|
2. Left
axis deviation (-30 to -90). Also check lead II.
To be true left axis deviation, it should also be down in lead II. If the
QRS is upright in II, the axis is still normal (0 to -30) |
Positive
|
Negative
|
3. Right
axis deviation (+90 to +180) |
Negative
|
Positive
|
4. Indeterminate
axis (-90 to -180) |
Negative
|
Negative
|
Normal axis
![Normal Axis trace](fig29normalaxis.jpg)
Left axis deviation
![Left axis deviation](fig30lad.jpg)
Right axis deviation
![right axis deviation](ecg17rad.jpg)
The bottom line is, if the axis is
shifted out of the normal quadrant, evaluate the reasons for
this.
|
Differential Diagnosis |
Left axis deviation |
LVH, left anterior fascicular block,
inferior wall MI |
Right axis deviation |
RVH, left posterior fascicular block,
lateral wall MI |
[ ECG index ] |