as|c E6C |nterpretat|on

P wave atrIal depolarIzatIon

PP segment conductIon delay through A7 node
PP IntervaI atrIal depolarIzatIon and conductIon delay through A7 node
"PS ventrIcular depolarIzatIon
ST segment IsoelectrIc; ventrIcles stIll depolarIzed
"T IntervaI ventrIcular depolarIzatIon and ventrIcular repolarIzatIon
T wave 7entrIcular repolarIzatIon


NormaI CardIac Phythm Parameters
ormal sInus rhythm between 60 and 100 bpm
SInus bradycardIa less than 60 bpm
SInus tachycardIa over 100 bpm
QFS wIdth between 0.08 and 0.12 sec
PF Interval between 0.12 and 0.20 sec
QT Interval 0.J00.40 sec
AtrIal rate, Inherent 60100 bpm
JunctIonal rate, Inherent 4060 bpm
7entrIcular rate, Inherent 2040 bpm


FCUFC FATE (for regular rhythms only)
1. 1500 method
dIvIde 1500 by the number of small squares between two consecutIve QFS complexes
2. FF method
fInd a QFS where the peak F wave falls on a heavy dark lIne. USe thIs QFS as reference then take note
where the next QFS falls. StartIng from the next heavy lIne, count J00, 150, 100, 75, 60, 50, 40.
J. 6second method
count the number of QFS complexes In a 6 second strIp and multIply by 10



How To Read An EKC?
The P Wave P waves are caused by atrial depolarization. !n
normal sinus rhythm, the SA node acts as the pacemaker. The electrical impulse from the SA node spreads over the
right and left atria to cause atrial depolarization. The P wave contour is usually smooth, entirely positive and of
uniform size. The P wave duration is normally less than 0.12 sec and the amplitude is normally less than 0.2S mv. A
negative Pwave can indicate depolarization arising from the Av node.
Note that the P wave corresponds to electrical impulses not mechanical atria contraction. Atrial contraction begins at
about the middle of the P wave and continues during the PR segment. The PR Segment PR segment is the portion on
the ECC wave from the end of the P wave to the beginning of the QRS complex, lasting about 0.1 seconds. The PR
segment corresponds to the time between the end of atrial depolarization to the onset of ventricular depolarization.
The PR segment is an isoelectric segment, that is, no wave or deflection is recorded. During the PR segment, the
impulse travels from the Av node through the conducting tissue (bundle branches, and Purkinje fibers) towards the
ventricles. Nost of the delay in the PR segment occurs in the Av node. Although the PR segment is isoelectric, the
atrial are actually contracting, filling the ventricles before ventricular systole.
The QRS Complex !n normal sinus rhythm, each P wave is followed by a QRS complex. The QRS complex
represents the time it takes for depolarization of the ventricles. The Q wave is not always present. The R wave is the
point when half of the ventricular myocardium has been depolarized. The normal QRS duration range is from 0.04
sec to 0.12 sec measured from the initial deflection of the QRS from the isoelectric line to the end of the QRS
complex.
Normal ventricular depolarization requires normal function of the right and left bundle branches. A block in either the
right or left bundle branch delays depolarization of the ventricles, resulting in a prolonged QRS duration.
The ST Segment The ST segment represents the period from the end of ventricular depolarization to the beginning
of ventricular repolarization. The ST segment lies between the end of the QRS complex and the initial deflection of
the Twave and is normally isoelectric. Although the ST segment is isoelectric, the ventricules are actually
contracting.
The T Wave The T wave corresponds to the rapid ventricular repolarization. The wave is normally rounded and
positive.

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EIectrocardiography
Electrocardiography is a quick, simple, painless procedure in which the heart's electrical impulses
are amplified and recorded on a piece of paper. This record, the electrocardiogram (ECG),
provides information about the part of the heart that triggers each heartbeat (the pacemaker), the
nerve conduction pathways of the heart, and the rate and rhythm of the heart.
Usually, an ECG is obtained if a heart disorder is suspected. t is also obtained as part of a
routine physical examination for most middle-aged and older people, even if they have no
evidence of a heart disorder. t can be used as a basis of comparison with later ECGs if a heart
disorder develops.

ECG: Reading the Waves

An electrocardiogram (ECG) represents the electrical current moving through the
heart during a heartbeat. The current's movement is divided into parts, and each part
is given an alphabetic designation in the ECG.
Each heartbeat begins with an impulse from the heart's pacemaker (sinus or
sinoatrial node). This impulse activates the upper chambers of the heart (atria). The
P wave represents activation of the atria.
Next, the electrical current flows down to the lower chambers of the heart
(ventricles). The QRS complex represents activation of the ventricles.
The electrical current then spreads back over the ventricles in the opposite direction.
This activity is called the recovery wave, which is represented by the T wave.
Many kinds of abnormalities can often be seen on an ECG. They include a previous
heart attack (myocardial infarction), an abnormal heart rhythm (arrhythmia), an
inadequate supply of blood and oxygen to the heart (ischemia), and excessive
thickening (hypertrophy) of the heart's muscular walls. Certain abnormalities on ECG
can also suggest bulges (aneurysms) that develop in weak areas of the heart's
walls. Aneurysms may result from a heart attack. f the rhythm is abnormal (too fast,
too slow, or irregular), the ECG may also indicate where in the heart the abnormal
rhythm starts. Such information helps doctors begin to determine the cause.

To obtain an ECG, an examiner places electrodes (small round sensors that stick to the skin) on
the person's arms, legs, and chest. These electrodes measure the magnitude and direction of
electrical currents in the heart during each heartbeat. The electrodes are connected by wires to a
machine, which produces a record (tracing) for each electrode. Each tracing shows the electrical
activity of the heart from different angles. The tracings constitute the ECG. ECG takes about 3
minutes, is painless, and has no risks.
Exercise Stress Testing
Testing the heart during exercise can help identify coronary artery disease. n coronary artery
disease, blood flow through the coronary arteries (which supply blood to the heart muscle) is
partly or completely blocked. f the coronary arteries are only partly blocked, the heart may have
an adequate blood supply when the person is resting but not when the person exercises. Thus,
testing the heart during exercise can help identify coronary artery disease. Because exercise
stress testing specifically monitors how the heart is functioning, the testing helps doctors
distinguish between problems due to a heart disorder and those due to other problems that limit
exercise, such as lung disorders, anemia, and poor general fitness.
Exercise testing has two components. Exercise or a drug is used to stress the heart, making it
beat faster, and the person is tested for signs of inadequate blood flow to the heart. The person is
also monitored for symptoms that suggest coronary artery disease, such as low blood pressure,
shortness of breath, and chest pain.
To stress the heart, most people walk on a treadmill or pedal an exercise bicycle. People who
cannot use their legs can use an arm crank. Gradually, the pace of the exercise and the force
required to do it (workload) are increased. The ECG is monitored continuously, and blood
pressure is measured at intervals. Usually, the person being tested is asked to keep going until
the heart rate reaches between 80% and 90% of the maximum for age and sex. f symptoms,
such as shortness of breath or chest pain, become too uncomfortable or if significant
abnormalities appear on the ECG or blood pressure recordings, the test is stopped sooner.
Testing takes about 30 minutes. Exercise stress testing has a small risk; the chance of its causing
a heart attack or death is 1 in 5,000.
People who cannot exercise can be evaluated using pharmacologic stress testing. For this
procedure, a drug, such as dipyridamole, dobutamine, or adenosine, is injected to simulate the
effects of exercise on blood flow.
Most commonly in stress testing, ECG is used to check for reduced blood flow in coronary
arteries. Sometimes more accurate, but more expensive tests, such as echocardiography and
radionuclide imaging, are performed as part of stress testing (see Symptoms and Diagnosis of
Heart and Blood Vessel Disorders: Radionuclide maging).
No test is perfect. Sometimes, these tests show abnormalities in people who do not have
coronary artery disease (a false-positive result), and sometimes tests do not show any
abnormalities in people who have the disease (a false-negative result). n people without
symptoms, especially younger people, the likelihood of coronary artery disease is low, despite an
abnormal test result. n such cases, a positive result is usually more likely to be false than true.
These false-positive results may cause considerable worry and medical expense. For these
reasons, most experts discourage routine exercise stress testing (such as for screening purposes
before an exercise program is begun or during an evaluation for life insurance) in people who do
not have symptoms.
Continuous AmbuIatory EIectrocardiography
Abnormal heart rhythms and inadequate blood flow to the heart muscle may occur only briefly or
unpredictably. To detect such problems, doctors may use continuous ambulatory ECG, in which
the ECG is recorded continuously for 24 hours while the person engages in normal daily
activities.
For this procedure, the person wears a small battery-powered device (Holter monitor) held on
with a shoulder strap. The monitor detects the heart's electrical activity through electrodes attached to the
chest and records the ECG. While wearing the monitor, the person notes in a diary the time and type of
any symptoms. Subsequently, the ECG is run through a computer, which analyzes the rate and rhythm of
the heart, looks for changes in electrical activity that could indicate inadequate blood flow to the heart
muscle, and produces a record of every heartbeat during the 24 hours. Symptoms recorded in the diary
can then be correlated with changes in the ECG.
f necessary, the ECG can be transmitted by telephone to a computer at the hospital or doctor's
office for an immediate reading as soon as symptoms occur.
An event monitor is used when a person must be monitored longer than 24 hours. t is similar to a
Holter monitor, but it records only when the user activates itthat is, when symptoms occur. f
symptoms occur so rarely that they cannot be captured during 24-hour monitoring, an event monitor
may be placed under the skin for up to a year. A small magnet is used to activate this monitor.
Continuous AmbuIatory BIood Pressure Monitoring
f the diagnosis of high blood pressure is in doubt (for example, if the measurements taken in the
office vary too much), a 24-hour blood pressure monitor may be used. The monitor is a portable battery-
operated device, worn on the hip, connected to a blood pressure cuff, worn on the arm. This monitor
repeatedly records blood pressure throughout the day and night over a 24- or 48-hour period. The
readings determine not only whether high blood pressure is present but also how severe it is.
EIectrophysioIogic Testing
Electrophysiologic testing is used to evaluate serious abnormalities in heart rhythm or electrical
conduction. Testing is performed in the hospital. After injecting a local anesthetic, a doctor inserts a
catheter with tiny electrodes at its tip through an incision, usually in the groin, into a vein or sometimes an
artery. The catheter is threaded through the major blood vessels into the heart chambers, using
fluoroscopy (a continuous x-ray procedure) for guidance. The catheter is used to record the ECG from
within the heart and to identify the precise location of the electrical conduction pathways.
Usually, a doctor intentionally provokes an abnormal heart rhythm during testing to find out
whether a particular drug can stop the disturbance or whether an operation will help by eliminating
abnormal electrical connections within the heart. f necessary, a doctor can quickly restore a normal
rhythm with a brief electrical shock to the heart (cardioversion). Although electrophysiologic testing is an
invasive procedure and an anesthetic is required, the procedure is very safe: The risk of death is 1 in
5,000. This procedure usually takes 1 to 2 hours.