Electrocardiography

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Arecordingoftheelectricalactivityoftheheartovertime
Goldstandardfordiagnosisofcardiacarrhythmias
Helpsdetectelectrolytedisturbances(hyper&hypokalemia)
Allowsfordetectionofconductionabnormalities
Screeningtoolforischemicheartdiseaseduringstresstests
Helpfulwithnoncardiacdiseases(e.g.pulmonaryembolismor
hypothermia

Electrocardiogram(ECG/EKG)
Isarecordingofelectricalactivityofheartconductedthruionsin
bodytosurface

Fig 13.22a

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ECGGraphPaper

Runsatapaperspeedof25mm/sec
EachsmallblockofECGpaperis1mm2
Atapaperspeedof25mm/s,onesmallblockequals0.04s
Fivesmallblocksmakeup1largeblockwhichtranslatesinto0.20
s(200msec)
Hence,thereare5largeblockspersecond
Voltage:1mm=0.1mVbetweeneachindividualblockvertically

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Normalconductionpathway:

SAnode>atrialmuscle>AVnode>bundleofHis>Leftand
RightBundleBranches>Ventricularmuscle

RecordingoftheECG:
Leadsused:
LimbleadsareI,II,II.Socalledbecauseatonetimesubjects
hadtoliterallyplacearmsandlegsinbucketsofsaltwater.
Eachoftheleadsarebipolar;i.e.,itrequirestwosensorsonthe
skintomakealead.
Ifoneconnectsalinebetweentwosensors,onehasavector.
Therewillbeapositiveendatoneelectrodeandnegativeatthe
other.
ThepositioningforleadsI,II,andIIIwerefirstgivenby
Einthoven.FormthebasisofEinthovenstriangle.

TypesofECGRecordings
Bipolarleadsrecordvoltage
betweenelectrodesplacedon
wrists&legs(rightlegis
ground)
LeadIrecordsbetweenright
arm&leftarm
LeadII:rightarm&leftleg
LeadIII:leftarm&leftleg

Fig 13.23
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Fig.13.22b

ECG
3distinctwavesare
producedduring
cardiaccycle
Pwavecausedby
atrialdepolarization
QRScomplexcaused
byventricular
depolarization
Twaveresultsfrom
ventricular
repolarization

Fig 13.24

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ElementsoftheECG:
Pwave:Depolarizationofbothatria;
RelationshipbetweenPandQRShelpsdistinguishvariouscardiac
arrhythmias
ShapeanddurationofPmayindicateatrialenlargement

PRinterval:fromonsetofPwavetoonsetofQRS
Normalduration=0.122.0sec(120200ms)(34horizontalboxes)
Representsatriatoventricularconductiontime(throughHisbundle)
ProlongedPRintervalmayindicatea1stdegreeheartblock
QRScomplex:Ventriculardepolarization
LargerthanPwavebecauseofgreatermusclemassofventricles
Normalduration=0.080.12seconds
Itsduration,amplitude,andmorphologyareusefulindiagnosingcardiac
arrhythmias,ventricularhypertrophy,MI,electrolytederangement,etc.
Qwavegreaterthan1/3theheightoftheRwave,greaterthan0.04secare
abnormalandmayrepresentMI

STsegment:
ConnectstheQRScomplexandTwave
Durationof0.080.12sec(80120msec
Twave:
Representsrepolarizationorrecoveryofventricles
IntervalfrombeginningofQRStoapexofTisreferredto
astheabsoluterefractoryperiod
QTInterval
MeasuredfrombeginningofQRStotheendoftheTwave
NormalQTisusuallyabout0.40sec
QTintervalvariesbasedonheartrate

Fig.13.24b

Fig.13.24c

Fig.13.24d

ElementsoftheECG:

Pwave
Depolarizationofbothatria;

RelationshipbetweenPandQRShelpsdistinguishvarious
cardiacarrhythmias
ShapeanddurationofPmayindicateatrialenlargement

QRScomplex:
Representsventriculardepolarization
LargerthanPwavebecauseofgreatermusclemassofventricles
Normalduration=0.080.12seconds
Itsduration,amplitude,andmorphologyareusefulindiagnosingcardiac
arrhythmias,ventricularhypertrophy,MI,electrolytederangement,etc.
Qwavegreaterthan1/3theheightoftheRwave,greaterthan0.04secare
abnormalandmayrepresentMI

PRinterval:
FromonsetofPwavetoonsetofQRS
Normalduration=0.122.0sec(120200ms)(34horizontal
boxes)
Representsatriatoventricularconductiontime(throughHis
bundle)
ProlongedPRintervalmayindicatea1stdegreeheartblock

Fig.13.24g

Twave:

Representsrepolarizationorrecoveryofventricles
IntervalfrombeginningofQRStoapexofTisreferredto
astheabsoluterefractoryperiod

STsegment:

ConnectstheQRScomplexandTwave
Durationof0.080.12sec(80120msec

QTInterval

MeasuredfrombeginningofQRStotheendoftheTwave
NormalQTisusuallyabout0.40sec
QTintervalvariesbasedonheartrate

IschemicHeartDisease
Ismostcommonlyduetoatherosclerosisin
coronaryarteries
Ischemiaoccurswhenbloodsupplytotissueis
deficient
Causesincreasedlacticacidfromanaerobicmetabolism

Oftenaccompaniedbyanginapectoris(chestpain)
Click here to play
Myocardial Infarction
RealMedia Movie
1378

IschemicHeartDisease
DetectablebychangesinSTsegmentofECG
Myocardialinfarction(MI)isaheartattack
Diagnosedbyhighlevelsofcreatinephosphate(CPK)&lactate
dehydrogenase(LDH)

Fig 13.34

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ArrhythmiasDetectedonECG
Arrhythmiasareabnormalheartrhythms
Heartrate<60/minisbradycardia;>100/minis
tachycardia

Fig 13.35

1380

ArrhythmiasDetectedonECGcontinued
Influttercontractionratescanbe200300/min
Infibrillationcontractionofmyocardialcellsis
uncoordinated&pumpingineffective
Ventricularfibrillationislifethreatening
Electricaldefibrillationresynchronizesheartbydepolarizingallcellsatsame
time

Fig 13.35

1381

ArrhythmiasDetectedonECGcontinued
AVnodeblockoccurwhennodeisdamaged
FirstdegreeAVnodeblockiswhenconductionthroughAVnode>
0.2sec
CauseslongPRinterval

SeconddegreeAVnodeblockiswhenonly1outof24atrialAPs
canpasstoventricles
CausesPwaveswithnoQRS

InthirddegreeorcompleteAVnodeblocknoatrialactivitypassesto
ventricles
VentriclesdrivenslowlybybundleofHisorPurkinjes

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ArrhythmiasDetectedonECGcontinued
AVnodeblockoccurswhennodeisdamaged
FirstdegreeAVnodeblockiswhenconduction
thruAVnode>0.2sec
CauseslongPRinterval
Fig 13.36

1383

ArrhythmiasDetectedonECGcontinued
SeconddegreeAVnodeblockiswhenonly1outof2
4atrialAPscanpasstoventricles
CausesPwaveswithnoQRS
Fig 13.36

1384

ArrhythmiasDetectedonECGcontinued
InthirddegreeorcompleteAVnodeblock,noatrialactivity
passestoventricles
VentriclesaredrivenslowlybybundleofHisorPurkinjes
Fig 13.36

1385

Representationinculture
InTVmedicaldramas,anisoelectricECG(nocardiacelectrical
activity,aka,flatline,isusedasasymbolofdeathorextreme
medicalperil.
Technically,thisisknownasasystole,aformofcardiacarrest,
withapartcularlybadprognosis.
Defibrillation,whichcanbeusedtocorrectarrythmiassuchas
ventricularfibrillationandpulselessventriculartachycardia,cannot
correctasystole.