Cardiac cycle

A. Consists of one beat, or one P-QRS-T sequence. 1. The sequence: Atrial contraction (systole) and relaxation (diastole), followed by ventricular contraction and relaxation 2. The cardiac cycle is measured on ECG from one R wave to the next R wave 3. Between cycles the ECG recorder returns to baseline or isoelectric line the flat line between the T wave and the next P wave B. Waveform deflections 1. Any waveform above the isoelectric line is positive (upright) 2. Any waveform below the isoelectric line is negative (downward) 3. Any waveform having both a positive and a negative component is called a biphasic deflection

Isoelectric line
The isoelectric line is the base line of the EKG. It is best seen by using the line between the end of a T wave and the beginning of the P wave of the next complex. EKG has a baseline or isoelectric line, which represents the absence of electrical activity.

ECG paper
A. The P-QRS-T sequence is recorded on special graph paper B. The vertical lines measure amplitude or voltage 1. Each small box represents 0.1 Mv 2. Each large block (made up of 5 small boxes) represents 0.5 mV 3. To determine the amplitude of a wave, segment or interval, count the number of small boxes from the baseline to the highest or lowest point C. The horizontal lines measure time 1. Each small box equals 0.04 seconds 2. Each large block (made up of 5 small boxes) equals 0.2 seconds (multiply 0.04 x 5 = 0.2) 3. The width of complexes and intervals are determined by the number of small boxes they extend over, then multiply by the time 0.04 4. When measuring or analyzing a heart rate or rhythm, a minimum of 6 seconds (30 large blocks) should be used

Waves and Intervals

P WAVE
1. The first deflection of the cardiac cycle 2. Represents depolarization of the atria 3. Begins as the waveform begins to leave the baseline, and ends when it returns to baseline 4. Normal: a) Location - precedes every QRS complex b) Amplitude - 0.5 to 2.5 mm high Rounded c) Duration - 0.06 to 0.12 seconds d) Configuration - small, rounded, similar in size and shape e) Deflection - positive (upright) in lead II 5. Normal P waves indicate: a) the electrical impulse originated in the SA node b) that normal depolarization of the atria occurred

Abnormal P waves:
a) Inverted - indicates reverse (retrograde) conduction from the AV junction backward toward the atria b) Peaked, notched or enlarged - the sinus impulse traveled through altered or damaged atria c) Varying - the impulse may be coming from different sites d) Absent - conduction by a route other that the SA node e) Not preceding a QRS - heart block

Normal P WAVE

Prolonged P WAVE

Inverted P WAVE

Absent P WAVE

Tall P WAVE

PR INTERVAL
1. Represents the time required for the electrical impulse to leave the SA node and travel through the atria, AV node, bundle branches, and Purkinje fibers 2. Normal: a) Location - from the beginning of the P wave to the beginning of the QRS complex, includes the P wave and the short flat (isoelectric) line that follows it b) Amplitude - not measured c) Duration - 0.12 to 0.20 seconds 3. Normal PR interval indicates that the electrical impulse leaving the SA node was conducted through the entire electrical system within a

ABNORMAL PR INTERVAL
a) Short (1) Electrical impulse was conducted through an abnormal pathway that bypasses the AV node, or (2) The impulse originated in an ectopic site close to the AV junction b) Long - indicates the electrical impulse is delayed traveling through the AV node and bundle of His

Prolonged PR Interval

Normal PR Interval

Short PR Interval

QRS COMPLEX
1. Represents ventricular depolarization 2. Measured from the beginning of the QRS as the first wave leaves the baseline to the J point 3. J point a) The junction between the QRS and the ST segment b) Where the last wave of the complex begins to flatten out at, above, or below the baseline c) Elevation or depression of the ST

4. Normal: a) Location - follows the PR interval b) Amplitude - varies greatly c) Duration - 0.06 to 0.10 d) Configuration (use figure 3-6, p18, Huff) (1) consists of the Q wave (the negative deflection before the R wave), the R wave (the first positive deflection after the Q wave), the S wave (the first negative deflection after the R wave) (2) May not always see all three waves. (3) The second R or S waves are labeled R'(R prime) or S'(S prime) e) Deflection - different in each lead 5. Normal QRS indicates that ventricular depolarization occurred within a normal amount of time

ABNORMAL QRS COMPLEX

6. Abnormal (wide) QRS indicates that abnormal depolarization has occurred due to a) Bundle branch block b) Conduction through an abnormal pathway c) The impulse originated in an ectopic site in the ventricles

Wide QRS Complex

Normal QRS Complex

ST segment
1. Represents the end of ventricular conduction 2. Normal: a) Location - extends from the S wave to the beginning of the T wave b) Deflection - usually isoelectric 3. Normal indicates the end of ventricular depolarization and the beginning of repolarization 4. Abnormal a) Elevation is a sign of myocardial injury b) Depression is most often associated with myocardial ischemia

T wave
1. Represents ventricular recovery or repolarization 2. Normal: a) Location - follows the S wave b) Amplitude - 0.5 mm, greater in MCL c) Duration - duration 0.10 to 0.25 seconds d) Configuration - rounded, slightly asymmetrical (ascends more slowly than the descent) e) Deflection - usually positive 3. Abnormal T waves indicate abnormal repolarization has occurred

QT interval
1. Measures ventricular depolarization and repolarization 2. Normal: a) Location - from the beginning of the QRS to the end of the T wave b) Duration (1) Varies according to heart rate, influence of medications, and other factors (2) Should not be greater than half the distance between two regular R waves 3. Abnormal: a) Long - indicates that ventricular repolarization time has slowed, which means that the relative refractory period (the vulnerable period) of the cardiac cycle is longer, predisposing patients to potentially lethal ventricular dysrhythmias b) Short - may result from digitalis toxicity or hypercalcemia

U wave
1. Represents the recovery period of the Purkinje fibers 2. Is not present of every rhythm strip, best seen with slow heart rates 3. Configuration is the most important characteristic 4. Normal: a) Location - after the T wave and before the next P wave b) Configuration - upright and rounded c) Deflection - upright 5. Abnormal - prominent U waves may be due to hypercalcemia, hypokalemia or digitalis toxicity

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