E C G PR O C E D U R E .

E C H O C AR D I O G RA P H Y

Definition:
Electrocardiography is a commonly used, noninvasive procedure for recording
electrical changes in the heart. The record, which is called an electrocardiogram
(ECG or EKG), shows the series of waves that relate to the electrical impulses that
occur during each beat of the heart. The results are printed on paper and/or
displayed on a monitor to provide a visual representation of heart function. The
waves in a normal record are named P, Q, R, S, and T, and follow in alphabetical
order. The number of waves may vary, and other waves may be present .

Purpose:
Electrocardiography is a starting point for detecting many cardiac problems, including
angina pectoris, stable angina, ischemic heart disease, arrhythmias (irregular heartbeat),
tachycardia (fast heartbeat), bradycardia (slow heartbeat), myocardial infarction (heart
attack), and certain congenital heart conditions. It is used routinely in physical examinations
and for monitoring a patient's condition during and after surgery, as well as in the intensive
care setting. It is the basic measurement used in exercise tolerance tests (i.e., stress tests)
and is also used to evaluate symptoms such as chest pain, shortness of breath, and
palpitations.

Description of the procedure

The patient disrobes from the waist up, and electrodes (tiny wires in adhesive pads) are
applied to specific sites on the arms, legs, and chest. When attached, these electrodes are
called leads; three to 12 leads may be employed for the procedure.
Muscle movement may interfere with the recording, which lasts for several beats of the
heart. In cases where rhythm disturbances are suspected to be infrequent, the patient may
wear a small Holter monitor in order to record continuously over a 24-hour period. This is
known as ambulatory monitoring.
Special training is required for interpretation of the electrocardiogram. To summarize in
the simplest manner the features used in interpretations, the P wave of the electrocardiogram
is associated with the contraction of the atriathe two chambers of the heart that receive
blood from the veins. The QRS series of waves, or QRS complex, is associated with
ventricular contraction, with the T wave coming after the contraction. The ventricles are the
two chambers of the heart that receive blood from the atria and that send the blood into the

arteries. Finally, the P-Q or P-R interval gives a value for the time taken for the electrical
impulse to travel from the atria to the ventricle (normally less than 0.2 seconds).

The most basic feature of the ECG is that the time from any one such peak to the same
one in the next cycle indicates precisely how long the heart cycle is taking. At slow rates, the
timing of the waves can be easily correlated to the heart sounds heard with the stethoscope.
But far more precise information can be gleaned once the relationship of the waves to the
phases of the cycle is understood:
The P-wave indicates the electrical activity associated with contraction of the cardiac
atria, the heart's upper chambers.
The PR interval is the delay between the beginning of activity in the atria and the
ventricles (atrioventricular conduction time). In adults, normal PR intervals range between
120 and 200 milliseconds, occasionally being shorter in children and slightly longer in the
aged. The PR interval shortens at high heart rates (e.g. due to exercise or to fever) and
increases at lower heart rates (e.g. during sleep).
The QRS complex indicates the onset of contraction of the ventricles. The shape of the
QRS complex may be modified by a number of physiological factors (e.g. body position and
breathing pattern). In normal adults, the duration of the QRS complex varies between 60 and
100 milliseconds; in children it tends to be shorter.
The QT interval is measured from the beginning of the QRS complex to the end of the
T-wave and represents the time between activation of electrical activity in the ventricles and
their return to the resting state. Like the PR interval, the QT interval shortens at high heart
rates and increases at lower rates.
The T-wave indicates when the electrical activity associated with the cells in the cardiac
ventricle returns to the resting state after electrical activation. Thus, it signals the start of
relaxation of the ventricle walls. It tends to be longer lasting than QRS because the onset of
relaxation across the ventricle is less tightly synchronized than that of contraction.

Risks
The EKG is a noninvasive procedure that is virtually risk-free for the patient. There is a
slight risk of heart attack for individuals undergoing a stress test EKG, but patients are
carefully screened for their suitability for this test before it is prescribed.Risk factors for heart
disease include obesity, hypertension (high blood pressure), high triglycerides and total blood
cholesterol, low HDL ("good") cholesterol, tobacco smoking, and increased age. People
who have diabetes mellitus (either type 1 or type 2) are also at increased risk for
cardiovascular disease.

Normal results
When the heart is operating normally, each part contracts in a specific order. Contraction
of the muscle is triggered by an electrical impulse. These electrical impulses travel through

specialized cells that form a conduction system. Following this pathway ensures that
contractions will occur in a coordinated manner.
When the presence of all waves is observed in the electrocardiogram, and these waves
follow the order defined alphabetically, the heart is said to show a normal sinus rhythm, and
impulses may be assumed to be following the regular conduction pathway.
In the normal heart, electrical impulsesat a rate of 60100 times per minuteoriginate in
the sinus node. The sinus node is located in the first chamber of the heart, known as the right
atrium, where blood reenters the heart after circulating through the body. After traveling down
to the junction between the upper and lower chambers, the signal stimulates the
atrioventricular node. From here, after a delay, it passes by specialized routes through the
lower chambers or ventricles. In many disease states, the passage of the electrical impulse
can be interrupted in a variety of ways, causing the heart to perform less efficiently.

The heart is described as showing arrhythmia or dysrhythmia when time intervals between
waves, or the order or the number of waves do not fit the normal pattern described above.
Other features that may be altered include the direction of wave deflection and wave widths.

Abnormal results
The cause of dysrhythmia is ectopic beats. Ectopic beats are premature heart beats that
arise from a site other than the sinus node-commonly from the atria, atrioventricular node, or
the ventricle. When these dysrhythmias are only occasional, they may produce no
symptoms, or a feeling of the heart turning over or "flip-flopping" may be experienced. These
occasional dysrhythmias are common in healthy people, but they also can be an indication of
heart disease.
The varied sources of dysrhythmias provide a wide range of alterations in the form of the
electrocardiogram. Ectopic beats that start in the ventricle display an abnormal QRS
complex. This can indicate disease associated with insufficient blood supply to the muscle
(myocardial ischemia). Multiple ectopic sites lead to rapid and uncoordinated contractions of
the atria or ventricles. This condition is known as fibrillation. In atrial fibrillation, P waves are
absent, and the QRS complex appears at erratic intervals, or "irregularly irregular."
When the atrial impulse fails to reach the ventricle, a condition known as heart
block results. If this is partial, the P-R interval (the time for the impulse to reach the ventricle)
is prolonged. If complete, the ventricles beat independently of the atria at about 40 beats per
minute, and the QRS complex is mostly dissociated from the P wave.

Alternatives
Electrocardiography is the gold standard for detecting heart conditions involving
irregularities in electrical conduction and rhythm. Other tests that may be used in conjunction
with an EKG include an echocardiogram (a sonogram of the heart's pumping action) and a
stress testan EKG that is done in conjunction with treadmill or other supervised exercise to
observe the heart's function under stressmay also be performed.

Bibliography

1. Gale Encyclopedia of Medicine, 3rd ed. | 2006 | Grant, Alison |

2. The Oxford Companion to the Body | 2001 | COLIN BLAKEMORE and SHELIA JENNETT
3. Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers | 2004 | Boleyn,
Maggie; Ford-Martin, Paula