Cuyahoga Community College NURS 2501

Acute Cardiac Breeze - EKG Interpretations – Basics Part 1

Slide 1: Hi Everyone, This presentation will cover some basic information about interpreting EKG’s. If
necessary, please review the anatomy of the heart, and blood flow through the heart before you begin.
We will begin with a quick review of cardiac physiology, discuss the heart’s conduction system, review
some terminology related to heart function, and then learn the major components of an EKG strip.

Slide 2: Let’s review the sequence of events in the cardiac cycle. If you recall from A & P, during one
heart beat, the heart muscles contract and then relax. The contraction phase is termed systole, while
relaxation is termed diastole. Diastole is about 2/3 of the cardiac cycle, and the heart muscle is relaxed
and filling of the atria and ventricles occurs. Systole is contraction and emptying of the atria and then the
ventricles.

Look at the image on the screen, starting on the left side. During atrial systole, the tricuspid and mitral
valves open and the atria contract, pushing blood into the ventricles. This atrial contraction, or what some
people term atrial kick, contributes about 30% to cardiac output. Notice the pulmonic valve and aortic
valve are closed at this time. As blood flows into the ventricles, pressure rises in the ventricles, forcing the
pulmonic and aortic valves to open, (image 3), and the ventricles contract pushing blood to the lungs from
the right side of the heart, and to the body from the left side of the heart. This is sometimes termed
ventricular ejection. In image 4, both the atria and ventricles relax (so this is diastole, right?), and the
atria fill with blood. Once atrial pressures exceed ventricular pressure the mitral valve and tricuspid valve
will open, and blood flows passively into the ventricles. This passive filling accounts for about 70% of
cardiac output. At this point atrial systole begins again, with atrial contraction, or that atrial kick.

Slide 3: The heart is supplied by two branches of the autonomic nervous system – a sympathetic branch,
also termed adrenergic, and a parasympathetic branch, also termed cholinergic.
SNS is the heart’s accelerator. Two hormones, epinephrine and norepinephrine speed up the heart rate
and increase contractility. So think of your car’s accelerator, the more you push the faster you go. The
more the sympathetic branch is stimulated the faster the heart rate.
PSN is the heart’s brakes. The vagus nerve and the neurotransmitter acetylcholine slow down the heart
rate. Now, think of your cars brake pedal. As you push on the brake, the car slows down.

Some cardiac medications affect these two systems. For example Beta-blockers, or sometimes you hear
beta-adrenergic blockers, block sympathetic activity, which decreases heart rate and contractility.
Atropine is an anticholinergic so it blocks acetylcholine and the vagus nerve’s effect on the heart, thereby
increasing the heart rate.

Slide 4: Without an electrical impulse, the heart cannot pump, or the cardiac cycle, which we just talked
about in slide 2 does not occur. Let’s review some terms that define the characteristics of cardiac cells.
Transmission of electrical impulses depends on these characteristics. The first is automaticity, which
refers to the cells ability to spontaneously initiate an impulse. Pacemaker cells of the heart have this
ability.
Excitability occurs from a shift of ions across the cell membrane; indicates how well a cell will respond to
an electrical stimulus.
Conductivity is the cells ability to transmit an electrical impulse to another cardiac cell.

The last characteristic is contractility, which refers to how well the cell contracts after receiving the
impulse.

As electrical impulses are transmitted, and ions like sodium, potassium, and calcium shift across the cell
membrane, cardiac cells depolarize and repolarize. Let’s talk about that briefly.

Slide 5: Cardiac cells at rest are polarized, meaning there is no electrical activity. This is termed the
resting potential. During rest, the inside of the cell is electrically negative while the outside is positive.
The depolarization-repolarization cycle consists of five phases, which make up the action potential curve.
The action potential curve shows the electrical changes within a myocardial cell.

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Cuyahoga Community College NURS 2501

During phase zero, (see the box on the left of the screen, the first swift upstoke), the cell receives an
impulse or stimulus and is depolarized, which initiates a heartbeat. During phase zero, Sodium moves
rapidly into the cell and Ca moves slowly into the cell. Think of this phase as the heart contracting.

Phase 1, which is at the peak of the straight upward stroke, is early repolarization and the sodium
channels close so sodium can no longer move intracellular. Phase 2 is the plateau area, a period of
slower repolarization in which calcium continues to move into the cell and potassium continues to move
out of the cell. In phase 3 there is rapid repolarization as calcium channels close, potassium continues to
flow out, and by the end of phase 3 the sodium/potassium pump begins restoring potassium in the cell
and sodium outside the cell. During phases 1, 2 & the early phase of 3, the cardiac cell is said to be in
absolute refractory period, which means no impulse, no matter how strong, can excite the cell. Think of
repolarization as the resting phase of the heart.

During the last portion of phase 3, a very strong stimulus can depolarized the cell. This is referred to as
the relative refractory period. Finally, Phase 4 is the resting phase of the action potential. By the end of
phase 4, cardiac cells are ready for another stimulus and depolarization. All this electrical activity is visible
on an EKG. The EKG represents only the electrical activity of the heart.

This is a bit complicated, and is not necessary to memorize. However, knowing that sodium, potassium
and calcium are moving across the cardiac cell membrane during the action potential will help you
understand some of the cardiac medications. Abnormalities of the heart or the hearts conduction system
alter the action potential leading to the development of cardiac arrhythmias.

Antiarrhythmic drug can directly affect the action potential. For example, there are sodium channel
blockers, potassium channel blockers, and calcium channel blockers.

Slide 6: Waveforms on an EKG represent the depolarization-repolarization cycle. Before we look at the
EKG waves forms, lets look at the conduction system of the heart. A normal cardiac impulse begins in the
sinoatrial node or SA node located in the R upper atrium. See #1 on the image. The SA node is the
heart’s primary pacemaker, and can generate an electrical impulse 60-100 x per minute. The impulse or
electrical stimulus generated by the SA node then travels through both atria via internodal pathways. The
stimulus is transmitted to the atrioventricular node or AV node, #2 on the image. The electrical impulse is
delayed slightly at the AV node before it travels down the atrioventricular bundle, sometimes called the
bundle of His, which separates into an R & L bundle branch, #3 on the image. Finally, the impulse
reaches the Purkinje fibers, #4.

Slide 7: Look at the image on the left of the screen. When the SA node generates an electrical impulse,
the impulse moves through the atria causing atrial depolarization. We see this as the P wave on the EKG.
When the impulse is delayed slightly at the AV node, we see this on the EKG as the PR segment (look at
the image on the right and find the PR segment. This short delay allows full atrial contraction, or that atrial
kick I mentioned before. At this point, the ventricles are filling. The impulse has now traveled down the AV
bundle and to the Purkinje fibers. The large QRS wave represents ventricular depolarization or
contraction. The ST segment and T wave represents ventricular repolarization.

Let's look at another view of these waveforms.

Slide 8: This image shows the EKG waveforms and explains what each part represents related to the
conduction system and depolarization and repolarization. A quick review, The P wave is the pacemaker
(SA node) initiating the electrical impulse. The P wave through the PR interval represents atrial
contraction or atrial depolarization. The QRS wave represents ventricular depolarization, and from the S
through to the U wave is ventricular repolarization.

Now let’s learn about the EKG paper and what the boxes represent. Please proceed to Part 2.

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