9

Electrocardiography

Key Points

• Electrocardiography is most useful in cats for the following indications, in decreasing order of diagnostic yield: cardiac
arrhythmias, metabolic abnormalities, and structural heart disease.
• The position of the limbs can affect the ECG results substantially in cats.
• Recording multiple leads helps the clinician choose the clearest tracing and makes ECG interpretation easier and more
accurate.
• Normal values for the feline ECG are listed on the inside covers of this book.

INTRODUCTION numerous potential artifacts, make many interpreta-

The first feline electrocardiogram (ECG) was performed
on a kitten by Augustus Waller in 1887 (Waller 1887,
1888, 1889). Today, the main clinical indication for elec-
trocardiography in cats is to assess the rhythm of the
heartbeat, commonly when an irregular or otherwise
abnormal rhythm (arrhythmia) is detected during phys-
ical exam, a patient is being monitored in the intensive
care unit, or during general anesthesia. Additional appli-
cations include assessment of cardiac dimensions, for
which an ECG is a poor substitute for an echocardio-
gram, and monitoring of such extracardiac disturbances
as hyperkalemia and hypoxemia (Tilley 1992; Côté 2010;
Côté and Harpster 2009; Fox and Harpster 1999). The
abbreviations ECG and EKG are used interchangeably;
EKG was the original Dutch spelling (elektrokardio-
gramm) put forth by the father of electrocardiography,
Willem Einthoven, and this has been replaced only par-
tially by ECG in English.
TECHNIQUE
A great deal of the interpretation of a feline ECG depends
on ECG quality. The small amplitude of deflections, and
tions challenging, and a poor quality tracing may not be
interpretable by even the most skilled cardiologist. Using
multiple ECG leads provides additional information
that may be missed on a single-lead strip, and by con-
vention a complete ECG in the cat displays 10 leads (see
Figure 9.1). Recording multiple leads provides addi-
tional information where lead II, or any other single
lead, may be inadequate (see Figure 9.2).
A cat’s ECG may be obtained with the patient in any
position, but the standard technique requires the cat to
be in right lateral recumbency. Left lateral and sternal
recumbencies have been evaluated in feline ECGs
(Harvey et al. 2005; Gompf and Tilley 1979; Calvert and
Coulter 1981), with conflicting results. Some studies
identified little difference between recumbencies
(Gompf and Tilley 1979; Calvert and Coulter 1981),
whereas a more recent study demonstrated significantly
smaller R waves when the ECG is recorded with cats in
left lateral or sternal recumbency compared to right
lateral recumbency and a mean electrical axis that is
significantly different in left versus right lateral recum-
bency (Harvey et al. 2005). At least part of the explana-
tion for this discrepancy likely relates to the position of
the electrodes on the limbs. As demonstrated in an

Feline Cardiology, First Edition. Etienne Côté, Kristin A. MacDonald, Kathryn M. Meurs, Meg M. Sleeper.
© 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc.

77
 78 Section B: Diagnostic Testing

I aVR V1 V4
QRS T QRS QRS
P
P T P T P
QRS T
Diagnostic Testing

II QRS aVL V2 V5

P P T
T
P T
QRS
QRS
III aVF V3 V6
QRS QRS QRS
P T P P
T
T

II QRS
P T

Figure 9.1. Normal sinus rhythm in a cat. Ten-lead tracing with zoomed inserts for each lead identifying the components of the heart-
beat. The heart rate is 160 beats/minute and the mean electrical axis is +90°. 25 mm/sec, 1 cm = 1 mV.

I aVR V1 V4

QRS
II aVL V2 V5
P T

III aVF V3 V6

Figure 9.2. Advantage of multiple leads: the limb leads (I, II, III, aVR, aVL, aVF) are difficult to interpret due to severe motion artifact.
In this cat, the precordial leads are much clearer, especially lead V2 (P, QRS, T labeled). 25 mm/sec; 1 cm = 1 mV.

elegant and striking case report, the natural tendency of
cats, when in lateral recumbency, to flex the elbows and
shoulders into a tucked, crouched posture changes the
position of the ECG electrodes, which in turn can dra-
matically alter the amplitude of ECG deflections and the
resulting mean electrical axis (Bond 2005) (Figure 9.3).
Any recumbency will do if only the rhythm is being
assessed, but if dimensions of waves and complexes are
being measured in an attempt to infer cardiac size and
structure, right lateral recumbency and proper restraint
and positioning are required. An optimal tracing is most
likely to result when the cat is gently held recumbent on
a comfortable, nonconductive surface (e.g., rubber-
coated foam mat) in a quiet area. For right lateral
recumbency, an assistant holds all four limbs pointing
away from himself/herself, toward the clinician record-
ing the tracing. Typically the assistant holds the fore-
limbs in the right hand, with an index finger between
right and left paws for comfort, and the hindlimbs in the
same manner in the left hand. The right wrist lies gently
over the cat’s neck and the left forearm may rest over the
cat’s left lateral thigh. An Elizabethan collar is recom-
mended for most cats as a precaution against the cat’s
quick turning and biting the assistant’s wrist. The ECG
electrodes, which are typically alligator-type clips, should
be of the minimally traumatic type (Figure 9.4), and
these are placed immediately distal to the right (RA) and
left (LA) elbows and right (RL) and left (LL) stifles.
 Chapter 9: Electrocardiography 79

Diagnostic Testing
A
B
I II III aVR aVL aVF
I II III aVR aVL aVF

Figure 9.3. Correct and incorrect technique for obtaining the ECG in a cat, illustrating the effect of limb position as described by Bond
(2005). The standard position involves placing the cat in right lateral recumbency, with the forelimbs pointing toward the clinician re-
cording the ECG. (A) Correct technique. The limbs are held properly, with both humeri and both femurs (black bars) perpendicular to the
long axis of the body. The mean electrical axis is −100°. The tracing is easily interpreted in all leads. (B) Incorrect technique. The cat is
allowed to flex the shoulders and elbows naturally, which alters the location of the ECG electrodes. This posture is common and needs
to be gently changed with steady traction to the limbs to produce the position shown in (A). The tracing associated with the crouched
posture is difficult to interpret in several leads due to decreased P wave and QRS complex amplitude. The apparent mean electrical axis
is altered by 50° (now −150°). This form of artifact may explain at least part of the poor sensitivity and specificity of mean electrical axis
for identifying changes in ventricular size and structure in the cat compared to the dog and human. 25 mm/sec, 1 cm = 1 mV.

costal space at the costochondral junction (V4, marked

YES NO
Figure 9.4. Close-up of a minimally traumatic ECG clip (YES) and
a metal alligator clip (NO) for connecting the ECG to the patient.
The alligator-type clip has fallen out of favor due to tissue trauma
and the discomfort it causes to patients.
Electrodes to derive the 4 precordial leads are placed at
the right 4th intercostal space just to the right of the
sternum (rV2, marked “V1” on the clip; formerly
CV5RL), at the left 5th intercostal space just to the left
of the sternum (V2; formerly CV6LL), at the 5th inter-
“V3”; formerly CV6LU), and over the seventh thoracic
vertebra on the dorsal midline (V10, marked “V4”). The
advantage of these precordial leads is that they may
provide ECG information that is otherwise confusing
or absent from the limb leads (I, II, III, aVR, aVL, aVF)
(see Figures 9.1, 9.2). Contact between patient and elec-
trode must be optimized, usually by applying isopropyl
alcohol to the point of contact between the electrode
and the skin; ultrasound gel may be applied simultane-
ously to maintain good contact if prolonged ECG moni-
toring is anticipated (e.g., general anesthesia). A complete
ECG should always display all 6 leads and at least 1
precordial lead, so the clinician may pick the clearest one
for accurate interpretation. Lead II is less reliably the
clearest lead in cats compared to dogs, and P waves, or
even QRS complexes, often may be difficult to distin-
guish in lead II but clearly apparent in another lead
(Figure 9.5; see Figure 9.2). Typically the duration of
recording is 1 minute, with 12–15 seconds of recording
in multiple leads and a rhythm strip that records 1, 3, or
more leads simultaneously at 10, 25, or 50 mm/sec for
the remainder of the minute. The expected results in
normal cats have been well documented (Blok and
Boeles 1957; Hamlin et al.; Massmann and Opitz 1954;
 80 Section B: Diagnostic Testing

-90° mitter pack are attached to the cat and the cat can move
-120° -60° and behave normally in his/her cage in the intensive care
unit.
A superior alternative is Holter monitoring. Modern
+aVR +aVL
-150° -30° Holter monitors weigh 300–400 grams (<1 lb), and they
Diagnostic Testing

record the ECG continuously for periods ranging from

-180°
+180°
+150° +30°
+120° +60°
+III +II
+90°
+aVF
Figure 9.5. Hexaxial lead system diagram.
Robertson et al. 1976) and are listed in the inside covers
of this book.
NORMAL EVOLUTION OF THE ECG
THROUGH LIFE
At birth, a kitten’s heart rate is slightly higher (247 beats/
minute) than at 30 days of age (237 beats/minute). As
might be expected with postnatal changes of the pulmo-
nary circulation during the first 30 days of life, the mean
electrical axis shifts leftward toward a more normal
adult position, from the −150° to ± 180° segment to the
+120° to +150° segment (Gomes-Lourenço and Ferreira
2003).
HOLTER AND EVENT MONITORING
If an arrhythmia occurs only intermittently, it may not
be apparent on an ECG even though it is detected on
physical examination, is suspected to be responsible for
a cat’s clinical signs, or both. In these instances, telemet-
ric (wireless) monitoring may be useful. Three forms of
telemetry are available for cats: in-hospital cage-side
ECG, Holter monitoring, and cardiac event recording.
In-hospital cage-side ECG monitoring, typically per-
formed for 24 or 48 hours, introduces the element of a
foreign environment, which may cause sympathetic
stimulation that abolishes bradycardias (false negative
result). However, it is valuable for the patient whose
clinical signs or severity of episodes indicate a possible
life-threatening recurrence and the risk of death at
home. Ideally, ECG patch electrodes and a small trans-
24 hours (most commonly) up to 6 days, usually on
multiple leads simultaneously (Côté 2010; Petrie 2005).
0° The information is stored digitally, although in older
+I
0° models an audiocassette inside the monitor may be used
for data recording. Veterinarians can rent Holter moni-
tors from various suppliers, including such online
sources as www.vetheart.com, www.albamedical.com,
www.labcorp.com, www.vetcardio.com, www.idexx.com,
and www.pdsheart.com. Owners need to maintain a
diary of the patient’s activities—and lack thereof—
during the entire monitoring period to provide a context
for analysis of the tracing. For example, a heart rate of
90 bpm is normal for a sleeping cat, but it would be an
important finding if it occurred during physical activity.
A feline patient’s Holter report, if produced through
human cardiology software, should be reviewed care-
fully. Automated reviewing is attractive because manual
review of Holter studies in cats has been documented
to take up to 2 hours of interpretation per hour of
recording. However, in automated review, over- and
underinterpretation are common, because software
designed for automated analysis of feline Holter record-
ings does not exist at this time. It remains the veterinar-
ian’s obligation to assess the abnormal ECG segments
shown in the Holter report and to decide whether the
interpretation correlates well with the rest of the patient’s
information.
The third type of telemetric ECG monitor is the
cardiac event monitor (Figure 9.6). Event monitors
continuously receive ECG information into a loop
memory system, which can only retain the information
temporarily. When an episode of clinical signs is
observed, the owner needs to trigger the event monitor.
Doing so saves an exact segment of ECG information
in the monitor’s memory. Several episodes can thus
be recorded over a number of days and the ECG can
then be printed out either at the veterinary hospital or,
in the case of external event monitors (Figure 9.6),
transtelephonically.
External event monitors are approximately the size of
a deck of cards (1 × 5 × 10 cm) and provide 7 to 30 days
of monitoring time (Bright and Cali 2000; Côté 2009).
External event monitors are connected to patients using
two or three wires attached to cutaneous ECG electrode
patches, one on each side of the chest over the heart
(modified precordial lead). The memory capacity of
external event monitors ranges from 5 to 18 minutes,

A
B is retrieved after the episode is over, using a pacemaker
Figure 9.6. Cardiac event monitors. (A) External event monitor
(left) and implantable event recorder (upper right) with its exter-
nal, owner-operated activator (lower right). (B) Cat instrumented
with an external event monitor. The monitors are light (100 g; less
than 1/4 lb.) and tolerated by most cats when lightly wrapped
using roll gauze and elastic wrap. Courtesy of Dr. Christopher
Rocchio, Cottonwood Images, and Veterinary Learning Systems.
and the monitors are programmed beforehand to save a
selected amount of ECG information (e.g., 45 seconds
preceding the push of the button and 15 seconds after it
for each triggered episode). They are available for use
from various sources, including many of those listed
previously for Holter monitors.
Internal event monitors (implantable loop recorders
[ILRs], Reveal® monitors) are for extended periods of
ECG assessment. These units consist of two parts: the
monitor and the patient (owner) activator (see Figure
9.6). The monitor itself is implanted subcutaneously in
the patient, whereas the owner-activated remote control
is a handheld device that can be applied over the skin
where the monitor lies in order to trigger the monitor
at the time of a clinical event. These monitors can also
be programmed so that they are triggered to record
Chapter 9: Electrocardiography 81
Diagnostic Testing
Figure 9.7. Cat instrumented with Holter monitor. With a light
but secure wrap, modern Holter monitors are sufficiently light
that they can be worn comfortably by cats. Photograph courtesy
of Dr. Fiona Campbell.
when they sense significantly low or elevated heart rates
(the triggering rates are chosen by the programmer).
Internal event monitors measure 0.5 × 2 × 7 cm, about
the size of a man’s thumb; have a battery life of approxi-
mately 7 months; and have a memory capacity of about
1 hour of ECG recording. The information they capture
interrogator unit placed over the area of skin where the
monitor is located (requires a return trip to the veteri-
nary hospital). The use of both types of event monitors
is of proven diagnostic value in humans; both external,
and to a lesser extent so far, internal, monitors are in
accepted use in cats (Bright and Cali 2000; Côté 1999;
Krahn et al 1999). Each form of ambulatory ECG moni-
toring has its relative merits (Côté 2010). Holter moni-
tors are superior for screening the number of abnormal
heartbeats on the ECG in a fixed 24- or 48-hour period,
such as for assessing a cat’s arrhythmia before and during
treatment with an antiarrhythmic drug (Figure 9.7).
Conversely, external event monitors also have a number
of advantages: they are smaller and lighter (3.5 oz [100 g],
compared with up to 14 oz [400 g] for a Holter monitor),
making them especially practical for cats; they have a
longer memory (at least 1 week, and up to 30 days in
certain models), which is useful for episodes occurring
less frequently; they eliminate some uncertainty of
interpretation by directly associating the ECG informa-
tion with an owner-observed event; and external event
monitors can transmit the acquired ECG information
transtelephonically, allowing the monitor to be reset and
a new monitoring period to begin without a return visit
to the hospital.