Electrocardiography

CC Apostol, Alanis May P. Consultant:

Department of Internal Medicine Residents-in-charge:
Iloilo Doctors’ Hospital, Inc. Dr. Delicana
September 20, 2021 Dr. Estrella
 Objectives
1. To review the cardiac anatomy and physiology related to electrocardiography
2. To identify and briefly discuss electrocardiography, its components and abnormalities
3. To discuss the basic steps in ECG reading
4. To differentiate and recognize rhythm disorders
The Heart
Layers of the Heart
Valves of the Heart
Blood Flow through the Heart
 Mechanisms of Heart Function

Diastole – relaxation
Systole – contraction
 Cardiac Output, Heart Rate & Stroke Volume

Blood Pressure (mmHg) • Cardiac Output (mL/min) X Systemic Vascular Resistance (SVR)

Cardiac Output (mL/min) • Heart rate (beats/min) X Stroke volume (mL/beats)

Heart Rate (beats/min) • Number of times the heart beats per minute.
• End-diastolic volume (EDV) – End-systolic volume (ESV)
• 3 factors affecting SV:
Stroke Volume (mL/beats) 1. Preload
2. Afterload
3. Contractility
Frank-Starling Mechanism
 Cardiac Cells

• Generate electrical impulse independent from the

Automaticity
nervous system
Excitability • Response to the electrical stimulus
• Propagate electrical impulse from cell to cell
Conductivity
through the heart
• Refers to how well the cell contracts after
Contractility
receiving a stimulus
 Cardiac Cells

● Electrically polarized
● Depolarization – lose the internal
negativity
● Repolarization – restore the
internal negativity
 Phases of Cardiac Muscle Action Potential

● Phase 0 – Rapid depolarization

● Phase 1 – Initial repolarization
● Phase 2 – Plateau Phase
● Phase 3 – Rapid repolarization
● Phase 4 – Resting phase
 Electrophysiologic Background

3 components that causes electric

currents:
1. Cardiac pacemaker
• Sinoatrial (SA) node
2. Specialized conduction tissue
• Atrioventricular (AV) node
• Bundle of His
• Right and Left Bundle of His
• Purkinje fibers
3. Heart muscle
THE CARDIAC
CONDUCTION SYSTEM
 SA (Sinoatrial) Node

Function Dominant pacemaker of the heart

In the wall of the right atrium in the upper
part of the sulcus terminalis just to the
Location
right of the opening of the superior vena
cava
Intrinsic Rate 60 to 100 beats per minute
 Internodal Pathways

Direct electrical impulses between SA node

Function and AV node and spread them across the
atrial muscle
3 Internodal Conduction Pathway
• Anterior Internodal Pathway
• Middle Internodal Pathway
• Posterior Internodal Pathway
 AV (Atrioventricular) Node

Slow conduction:
• Creating slight delay before an electrical
impulse carried to the ventricle
Function
• Allows rapid filling of the ventricles
before it contracts to pump out blood to
the circulation.
Lower part of the atrial septum just above
Location the attachment of the septal cusps of the
tricuspid valve
Intrinsic rate 40 to 60 beats per minute
 Bundle of His

Acts like a terminal roots for the

electrical impulses of the heart which
Function
trigger stimulation and contraction of
ventricles.
Located at the top of interventricular
septum
Location Extends directly from the AV Node
which connects the atria and the
ventricles electrically
 Left and Right Bundle Branch

Right Bundle Branch Left Bundle Branch

Carries electrical impulse at high speed to the

tissue of interventricular septum and to each
ventricles simultaneously.
 Purkinje System

Function Termination of bundle branches with

network of fibers, which spread
electrical impulses rapidly
throughout the ventricular walls
Intrinsic rate 20 to 40 beats per minute
Electrocardiography (ECG)
A graphic representation of electrical activity generated by the heart
 12-Lead Electrocardiogram (ECG)

• Records the heart’s electrical activity using a series of electrodes placed on

the patient’s extremities and chest wall.
• Includes:
o 6 limb leads
§ 3 bipolar leads: I, II and III
§ 3 unipolar (augmented) leads: aVF, aVR and aVL
o 6 chest (precordial) leads: V1, V2, V3, V4, V5, and V6
 Limb Leads

Standard Limb Leads

Positive Negative View of

Lead
Electrode Electrode Heart
I LA RA Lateral

II LL RA Inferior

III LL LA Inferior
 Limb Leads

Augmented Limb Leads

Positive
Lead View of Heart
Electrode
aVR RA None

aVL LA Lateral

aVF LL Inferior
 Chest Leads
Standard Chest Lead
View of the
Lead Positive Electrode
Heart
4th intercostal space, RIGHT
V1 Septum
parasternal border
4th intercostal space, LEFT
V2 Septum
parasternal border
V3 Between V2 and V4 Anterior
5th intercostal space, LEFT
V4 Anterior
midclavicular line
5th intercostal space, LEFT anterior
V5 Lateral
axillary line
5th intercostal space, LEFT
V6 Lateral
midaxillary line
 Chest Leads
Additional Leads in Special
Circumstances

Lead Positive Electrode View of the Heart

5th intercostal space, RIGHT

V4R Right ventricle
anterior midclavicular line
Posterior 5th intercostal Posterior wall of
V8
space, LEFT midscapular line the left ventricle
Between V8 and spinal
Posterior wall of
V9 column at posterior 5th
left ventricle
intercostal space
 Components of ECG

Electrical Activity
A positive or negative deflection away
Wave
from the baseline of the ECG tracing
Complex Several waves
A straight line between waves or
Segment
complexes
Interval A segment and a wave
 P Wave

Represents atrial depolarization

Location Precedes the QRS complex
Normal Duration 0.06-0.12 second
Normal Amplitude 2-3 millimeters
Configuration Small, rounded and upright
Deflection Positive and upright in leads I,II, aVF
and V2 to V6
 QRS Complex

Represents ventricular depolarization

Location Follows the PR Interval
Normal Duration 0.06-0.10 second
Normal Amplitude 5-30 millimeters
Configuration Q wave: first negative deflection after P wave
R wave: first positive deflection after the P wave
or the Q wave
S wave: first negative deflection after the R
wave
Deflection Positive in leads I, II, III, aVL, aVF, and V4 to V6
Negative in leads aVR and V1 to V3
 T Wave

Represents ventricular repolarization

Location Follows the S wave
Configuration Typically round and smooth
Deflection Upright in leads I, II, and V3 to V6
Inverted in lead aVR
Variable in all other leads
 U Wave

Location Follows the T wave

Configuration Typically upright or rounded
Deflection Upright
 PR Interval

Location From the beginning of the P wave to the

beginning of the QRS complex
Duration 0.12-0.20 second
 QT Interval

Location Extends from the beginning of the QRS

complex to the end of the T wave
Duration 0.44-0.46 second
 PR Segment

Location Flat line between the end of the P wave and

beginning of QRS complex
 ST Segment

Location Extends from the end of the S wave to the

beginning of the T wave
Deflection Usually isoelectric (neither positive nor
negative)
 Basic Steps in ECG Reading

1. Determine the rate

2. Determine the rhythm
3. Measure intervals
4. Determine QRS electrical axis
5. Check for chamber enlargements
6. Check for ST and T-wave changes
7. Check for other arrhythmias and abnormalities
 1
Determine the Rate
 Step 1 – Determine the Rate
● Look at lead II at the bottom part of the ECG strip
● Look at the number of square between one R-R interval
REGULAR RHYTHM IRREGULAR RHYTHM

30 large boxes = 6 seconds

Rate Slow (< 60 beats per minute)
Rhythm Regular
P Waves Normal (Upright and uniform)
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
Rate Fast (>100 beats per minute)
Rhythm Regular
P Waves Normal (upright and uniform)
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
 2
Determine the Rhythm
 Step 2 – Determine the Rhythm

Atrial rhythm: Measure the P-P interval

Ventricular rhythm: Measure the intervals between two consecutive R waves in the QRS complex

Paper and Pencil Method

Rate Normal (60-100 beats per minute)
Rhythm Regular
P Wave Normal (upright and uniform)
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
T Wave Normal (upright and round)
Pacemaker Sinoatrial (SA) node
Rate Variable
Rhythm Irregular
P Waves Normal (upright and uniform)
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
Junctional (Atrioventricular) Rhythm

Pacemaker Atrioventricular (AV) node

Rate 40-60 beats per minute
Rhythm R-R interval: regular
P Waves May appear inverted, after or buried within QRS complex
QRS Complex Narrow (≤0.12 second)
Pacemaker His-Purkinje system (HPS)
Rate 20-40 beats per minute
Rhythm R-R interval: regular
P Waves Absent
QRS Complex Wide (≥0.12 second)
 3
Measure Intervals
 Normal Values

• 0.06-0.12 second
P wave • Atrial depolarization
• ≤ 3 small squares
• Conduction delay • 0.12-0.20 second
PR Interval
within the AV node • ≤ 5small squares
• Ventricular • 0.06-0.10 second
QRS Complex
depolarization • ≤ 3 small squares
• 0.44-0.46 second
• Ventricular
• Upper limit:
QT Interval depolarization and
o Men: 0.45 second
repolarization
o Women: 0.46 second
 P Wave Abnormalities

Tall, rounded or peaked P waves

Notched, wide (enlarged) or biphasic P waves
Increased RIGHT atrial pressure and
atrial dilation Increased LEFT atrial pressure and atrial dilation

P pulmonale P mitrale
 PR Interval Abnormalities

● Wolff-Parkinson White Syndrome

● First-degree AV Block
● Second-degree AV Block
● High-grade AV Block
● Third-degree AV Block
 Wolff-Parkinson-White Syndrome
● Kent bundle
○ Conducts impulses to the atria or the
ventricles bypassing the internodal
pathways and AV node
● ECG findings
o Short PR interval (<0.12 second)
o Wide QRS (>0.12 second)
o Delta wave
 First-degree AV Block

● Prolonged PR interval (> 0.20 seconds) – constant

● P wave is always followed by a QRS complex, but with a slight delay
 Second-degree AV Block

Type I (Wenckebach)
• Progressively prolonged PR interval
followed by absence of QRS complex
(a drop)

Type II (Mobitz II)

• Consistent prolonged PR interval
followed by absence of QRS complex
(a drop)
 High-grade AV Block

● P waves and QRS complex – present

● PR interval – constant (may be normal or prolonged)
● Atrioventricular ratio of 3:1
○ 3 P waves : 1 QRS complex
 Third-degree AV Block (Complete Heart Block)

● PR interval – varies
● P and QRS waves occur regularly but independent of each other
● Escape rhythm – narrow or wide QRS complex
 QRS Complex Abnormalities

LEFT & RIGHT Bundle Branch Block

Recognizing LBBB:
● Lead V1 – note the rS or QS pattern
● Lead V6 – note the slurred R wave
and T wave inversion

Recognizing RBBB:
● Lead V1 – note the rSR’ pattern
(“bunny ears”) and T wave inversion
● Lead V6 – note the widened S wave
and upright T wave
 QT Interval Abnormalities

● Prolonged QT interval –
○ Increases the risk of a life-threatening arrhythmia (torsades de pointes)

Corrected QT-Interval (QTc) using Bazett’s Formula

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00 *+&$#,-. *+ 1$%"+'1
Normal QTc values
• Male: < 0.45 second
• Female: < 0.46 second
Torsades de pointes = QTc > 0.50 second in male & female
 QT Interval Abnormalities

Prolonged QT Interval
Medications
● Class IA antiarrhythmics
○ Quinidine
○ Procainamide
● Class III antiarrhythmics
○ Amiodarone
○ Ibutilide
○ Dofetilide
Hypocalcemia
Systemic hypothermia
● Presence of Osborn wave (J wave)
 QT Interval Abnormalities

Shortened QT Interval
● Hypercalcemia
 4
Determine QRS Electrical Axis
 QRS Electrical Axis

● The average direction of the heart’s

electrical activity during ventricular
depolarization
● Six limb leads:
○ Lead I, II, III, aVR, aVL and aVF
Interpretation Values
Normal Axis - 30º to + 90º
Moderate Right Axis Deviation + 90º to + 120º
Marked Right Axis Deviation + 120º to + 180º
Moderate Left Axis Deviation - 30º to - 45º
Marked Left Axis Deviation - 45º to - 90º
Extreme Axis Deviation - 90º to + 180º
 Determine the QRS Electrical Axis

Quadrant Method
● Fast, easy way to plot the heart’s axis
● QRS complex deflection in leads I and
aVF

Lead I Lead aVF Interpretation

Positive Positive Normal Axis

Positive Negative LEFT Axis Deviation

Negative Positive RIGHT Axis Deviation

Negative Negative Extreme Axis Deviation

 Determine the QRS Electrical Axis

Three-Lead Analysis (Lead I, II and aVF)

Lead I Lead II Lead aVF Interpretation

Positive Positive Positive/Negative Normal Axis

Positive Negative Negative LEFT Axis Deviation

Negative Positive Positive RIGHT Axis Deviation

Negative Negative Negative Extreme Axis Deviation

 5
Check for Chamber Enlargements
 Atrial Enlargement

RIGHT Atrial Enlargement LEFT Atrial Enlargement

• Lead II – peaked P • Lead II – wide,
wave notched/bifid P wave
• V1 – prominent initial • V1 – biphasic
positive deflection
• P pulmonale • P mitrale
 Ventricular Enlargement

● RIGHT Ventricular Hypertrophy

● LEFT Ventricular Hypertrophy
1. Sokolow-Lyon Criteria
2. Cornell Criteria
3. Romhilt-Estes Criteria
 Ventricular Enlargement

RIGHT Ventricular Hypertrophy

Criteria
• Right axis deviation (> 90º)
• Dominant R wave in V1 (> 7 mm tall or R/S ratio > 1)
• Dominant S wave in V5 or V6 (> 7 mm deep or R/S ratio < 1)
 Ventricular Enlargement

LEFT Ventricular Hypertrophy

Sokolow-Lyon Criteria
[S in V1] + [R in V5 or V6] > 35 mm
or
[R in aVL] > 11 mm
[18 mm] + [23 mm] = 41 mm ⇒ LVH
 Ventricular Enlargement

LEFT Ventricular Hypertrophy

Cornell Criteria
[S in V3] + [R in aVL]
• Male: ≥ 28 mm
• Female: ≥ 20 mm
[20 mm] + [9 mm] = 29 mm ⇒ LVH
 Ventricular Enlargement
LEFT Ventricular Hypertrophy
Romhilt-Estes Criteria
Criteria Points Scoring
Any limb lead R wave or S wave ≥ 2.0 mV (20 mm)
or S wave in V1 or V2 ≥ 3.0 mV (30 mm) 3
≥ 5 = DEFINITE LVH
or R wave in V5 or V6 ≥ 3.0 mV (30 mm)
ST-T wave changes typical of left ventricular hypertrophy (LVH)
• Taking digitalis 1 4 = Probable LVH

• Not taking digitalis 3

Left atrial abnormality
• P wave in V1: ≥ 0.1 mV (1 mm) in amplitude with a duration of 0.04 second 3
Left axis deviation > -30º 2
QRS duration ≥ 0.09 second 1
Intrinsicoid deflection in V5 or V6 ≥ 0.05 second 1
 6
Check for ST Segment and T Wave Changes
 Changes in ST Segment

ST-segment Depression ST-segment Elevation

• > 1 mm below the baseline • > 1 mm above the baseline
• May indicate myocardial ischemia • May indicate myocardial injury/infarction
 ST Segment and T Wave Changes

ECG changes associated with angina

Location of Myocardial Ischemia
 ST Segment Changes in Myocardial Infarction

Non-ST Segment Elevation MI (NSTEMI) ST Segment Elevation MI (STEMI)

• ST segment depression • ST segment elevation
• T wave inversion • Pathological Q wave formation
Sinoatrial (SA) Node Disorders

• Sinus Arrest
• Sinus Exit Block
• Sick Sinus Syndrome
 SA Node Disorders

Sinus Arrest
● A disorder of impulse formation
● Atrial standstill
○ Lack of electrical activity in the atrium
● ≥ 2 full PQRST is missing

PQRST complex is missing

Sinus Arrest

Rate Normal to slow; determined by duration& frequency of sinus pause/arrest

Rhythm Irregular whenever a pause/arrest occurs
P Waves Normal (upright and uniform) except in areas of pause (arrest)
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
Others Pause/arrest time interval is not a multiple of the normal PP interval
 SA Node Disorders

Sinus Exit Block

● Failure of impulse transmission
● PQRST wave followed by a pause (dropped beat) and absent P
wave then followed by QRS complex or an escaped beat
● 1 full PQRST is missing

Dropped beat Escaped beat

Rate Normal to slow; determined by duration and frequency of SA block
Rhythm Irregular whenever an SA block occurs
P Waves Normal (upright and uniform) except in areas of dropped beats
PR Interval Normal (0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
Others Block occurs in some multiple of the P-P interval
 SA Node Disorders

Sick Sinus Syndrome

● Sinus node dysfunction ● ECG findings
● Combination of symptoms ○ Sinus bradycardia
○ Dizziness ○ Episodes of sinus arrest or sinus
○ Confusion exit block
○ Fatigue ○ Sinus bradycardia alternating with
○ Syncope sinus tachycardia
○ Congestive heart failure ○ Supraventricular tachycardia such
● Bradycardia-tachycardia syndrome as atrial fibrillation and atrial
○ Paroxysms of other sinus flutter
tachyarrhythmias such as atrial ● Treatment
flutter and supraventricular ○ Pacemaker
tachycardia (SVT) ■ Temporary or permanent
■ Dual chamber pacemaker
Sick Sinus Syndrome
Supraventricular Tachyarrhythmias

● Atrial Flutter
● Atrial Fibrillation
 Atrial Flutter

● Results from circus reentry & possibly

increased automaticity
● Presence of flutter waves
○ Saw-toothed appearance
○ Commonly seen in leads II, III and aVF
● Atrial rate: 250-350 beats per minute
● Ventricular rate: usually half the atrial rate
● Commonly associated with second-degree AV
block
● Spontaneous conversion to atrial fibrillation
may occur
Rate Atrial: 250-350 beats per minute; ventricular: variable
Rhythm Atrial: regular; ventricular: variable
P Waves Flutter waves have a saw-toothed appearance
PR Interval Variable
QRS Complex Usually normal (0.06-0.10 second)
 Atrial Fibrillation

● Most common arrhythmia (SVT)

● Rapid, erratic electrical discharge from
multiple atrial ectopic foci
○ Due to firing of a number of
impulses in reentry pathways
● No discrete P waves
○ Replaced by fibrillatory waves
● Atrial rate: 350 – 600 beats per minute
● Ventricular rate: irregularly irregular
 Atrial Fibrillation

Lone Atrial Fibrillation Holiday Heart Syndrome

• Presence of A-fib in the absence of • A paroxysmal form of A-fib commonly seen with alcohol
underlying clinical heart disease abuse
ü Healthy patient
ü <60 years old
ü Asymptomatic
ü Normal echocardiogram
Atrial Fibrillation

Rate Atrial: ≥350 beats per minute; ventricular: variable

Rhythm Irregularly irregular
P Waves No true P waves; chaotic atrial activity
PR Interval None
QRS Complex Normal (0.06-0.10 second)
Ventricular Arrhythmias

● Ventricular Tachycardia
● Ventricular Fibrillation
 Ventricular Tachycardia

● ≥ 3 consecutive premature ventricular

contractions (PVCs) at a rate of > 100 beats
per minute
● May precede:
○ Ventricular fibrillation
○ Sudden cardiac death
● P wave: absent
● QRS complex: Rapid, bizarre, wide (> 0.10
second)
 Ventricular Tachycardia
Classification of V-tach
According to Duration
1. Sustained VT
V-tach: ≥ 30 seconds
2. Non-sustained VT
V-tach: < 30 seconds
According to Morphology
1. Monomorphic VT
o Rapid sequence of bizarre PVC-like wide QRS
complexes
§ P waves: absent
§ QRS complexes: same appearances
2. Polymorphic VT
o Beat-to-beat variations in appearance
§ QRS complexes: continually changing
Rate 187 beats per minute; ventricular rate: 100-250 beats per minute
Rhythm Variable (usually regular but may be slightly irregular)
P Waves Absent
PR Interval Unmeasurable
QRS Complex Wide, bizarre (0.16 second)
 Ventricular Tachycardia

Torsades de pointes

● “twisting about the points”

● A special form of polymorphic V-tach
● Paroxysmal rhythm
● Reversible
● May deteriorate into ventricular
fibrillation or asystole
● P waves: absent
● QRS complexes: wide with changing
amplitude
Torsades de Pointes

Rate 200-250 beats per minute

Rhythm Irregular
P Waves Absent
PR Interval Absent
QRS Complex Wide (>0.10 second), bizarre appearance
 Ventricular Fibrillation

● Chaotic pattern of electrical activity in

the ventricles
● No effective muscular contraction
● No effective cardiac output
○ May lead to ventricular landstill and
death
● No identifiable or distinct P waves, QRS
complexes or T waves
Rate Undetermined
Rhythm Chaotic
P Waves Absent
PR Interval Unmeasurable
QRS Complex Indiscernible
T Wave Indiscernible
Others Waveform is a wavy line
Premature Beats

● Premature Atrial Contractions

● Premature Ventricular Contractions
 Premature Atrial Contractions (PAC)

● Asymptomatic and benign

● Hallmark ECG characteristic
○ Premature P wave with abnormal configuration
Rate Depends on rate of underlying rhythm
Rhythm Irregular whenever a PAC occurs
P Waves Present; in the PAC, may have different shape
PR Interval Varies in the PAC; otherwise normal(0.12-0.20 second)
QRS Complex Normal (0.06-0.10 second)
 Premature Ventricular Contractions (PVC)

● Prematurely occurring QRS complex

○ Wide and bizarre-looking
○ Complete compensatory pause following every premature beat
● No preceding P waves
● T wave is opposite in deflection compared to QRS complex
● May occur as couplets, bigeminy and trigeminy
Couplets • 2 successive PVCs

• PVCs alternate with

Bigeminy every other beat

• PVC occur after

Trigeminy every 2 beats
• PVC every 3rd beats
Premature Ventricular Contraction (PVC)

Rate 120 beats per minute

Rhythm Irregular
P Waves Absent with PVC, but present with other QRS complex
PR Interval 0.12 second in underlying rhythm
QRS Complex Early with bizarre configuration; 0.14 sec in PVC; 0.8 sec in underlying rhythm
T Wave Opposite direction from QRS complex with PVC
Others Compensatory pause after PVC
Metabolic Disorders

● Hyperkalemia
● Hypokalemia
 Metabolic Disorders
Hyperkalemia
Mild to moderate Severe
• P wave – diminution in amplitude • P wave – absent
• PR interval – prolonged • ”sine wave” pattern
• QRS complex – widening • Causes asystole and cardiac arrest
• T wave – narrowing and peaking (tenting)
 Metabolic Disorders

Hypokalemia
● P wave – slightly peaked
● PR interval – slightly prolonged
● ST depression
● T wave – shallow
● Prominent U wave
Antiarrhythmic Drugs
Classification
 Vaughan-Williams Classification
Class Mechanism Examples
I Sodium-channel blockers
• Disopyramide
• Slows conduction velocity
Ia • Prolongs action potential duration
• Procainamide
• Quinidine
• Lidocaine
• No effect on conduction velocity
Ib • May shorten action potential duration
• Mexiletine
• Phenytoin
• Slows conduction velocity • Flecainide
Ic • May prolong action potential duration (mild) • Propafenone
• Propranolol
II Beta-adrenergic receptor blockers • Esmolol
• Amiodarone
• Dofetilide
III Potassium-channel blockers • Ibutilide
• Sotalol
• Verapamil
IV Calcium-channel blockers • Diltiazem
REFERENCES
 REFERENCES

● Lippincott Williams & Wilkins. (2005). ECG interpretation made incredibly easy.
Philadelphia, PA: Lippincott Williams & Wilkins.
● Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo,
J. (2015). Harrison's principles of internal medicine (20th edition.). New York:
McGraw Hill Education.
● Hall, J. E. (2015). Guyton and hall textbook of medical physiology (13th ed.). W B
Saunders.
● AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of
the Electrocardiogram. Circulation.
https://www.ahajournals.org/doi/10.1161/circulationaha.108.191095
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