Electrocardiography

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

Electrocardiogram(ECG/EKG)
Isarecordingofelectricalactivityofheartconductedthruionsin
bodytosurface

ECGGraphPaper

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

Normalconductionpathway:

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

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

ElementsoftheECG:
Pwave:Depolarizationofbothatria;
RelationshipbetweenPandQRShelpsdistinguishvariouscardiac
arrhythmias
ShapeanddurationofPmayindicateatrialenlargement

PRinterval:fromonsetofPwavetoonsetofQRS
Normalduration=0.122.0sec(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

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

Twave:

Representsrepolarizationorrecoveryofventricles
IntervalfrombeginningofQRStoapexofTisreferredto
astheabsoluterefractoryperiod

STsegment:

ConnectstheQRScomplexandTwave
Durationof0.080.12sec(80120msec

QTInterval

MeasuredfrombeginningofQRStotheendoftheTwave
NormalQTisusuallyabout0.40sec
QTintervalvariesbasedonheartrate

IschemicHeartDisease
Ismostcommonlyduetoatherosclerosisin
coronaryarteries
Ischemiaoccurswhenbloodsupplytotissueis
deficient
Causesincreasedlacticacidfromanaerobicmetabolism

Oftenaccompaniedbyanginapectoris(chestpain)

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

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

ArrhythmiasDetectedonECG
Influttercontractionratescanbe200300/min
Infibrillationcontractionofmyocardialcellsis
uncoordinated&pumpingineffective
Ventricularfibrillationislifethreatening
Electricaldefibrillationresynchronizesheartbydepolarizingallcellsatsame
time

ArrhythmiasDetectedonECG
AVnodeblockoccurwhennodeisdamaged
FirstdegreeAVnodeblockiswhenconductionthroughAVnode>
0.2sec
CauseslongPRinterval

SeconddegreeAVnodeblockiswhenonly1outof24atrialAPs
canpasstoventricles
CausesPwaveswithnoQRS

InthirddegreeorcompleteAVnodeblocknoatrialactivitypassesto
ventricles
VentriclesdrivenslowlybybundleofHisorPurkinjes

ArrhythmiasDetectedonECG
AVnodeblockoccurswhennodeisdamaged
FirstdegreeAVnodeblockiswhenconduction
thruAVnode>0.2sec
CauseslongPRinterval

ArrhythmiasDetectedonECG
SeconddegreeAVnodeblockiswhenonly1outof2
4atrialAPscanpasstoventricles
CausesPwaveswithnoQRS

ArrhythmiasDetectedonECG
InthirddegreeorcompleteAVnodeblock,noatrialactivity
passestoventricles
VentriclesaredrivenslowlybybundleofHisorPurkinjes