Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Save to My Library
Look up keyword
Like this
28Activity
0 of .
Results for:
No results containing your search query
P. 1
ECG Morphology

ECG Morphology

Ratings:

4.5

(2)
|Views: 1,487 |Likes:
Published by Mr Joko

More info:

Published by: Mr Joko on Dec 16, 2008
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

12/21/2012

pdf

text

original

 
1
The Morphology of the Electrocardiogram
 Antoni Bayés de Luna, Velislav N. Batchvarov andMarek Malik
The 12-lead electrocardiogram (ECG) is the single mostcommonly performed investigation. Almost everyhospitalized patient will undergo electrocardiography,and patients with known cardiovascular disease will doso many times. In addition, innumerable ECGs recordedare made for life insurance, occupational fitness androutine purposes. Most ECG machines are now able toread the tracing; many of the reports are accurate butsome are not. However, an accurate interpretation of the ECG requires not only the trace but also clinicaldetails relating to the patient. Thus, every cardiologistand physician/cardiologist should be able to understandand interpret the 12-lead ECG. Nowadays, manyother groups, for example accident and emergencyphysicians, anaesthetists, junior medical staff, coronarycare, cardiac service and chest pain nurses, also need a
Summary
good grounding in this skill. In the last several decadesa variety of new electrocardiographic techniques, suchas short- and long-term ambulatory ECG monitoringusing wearable or implantable devices, event ECGmonitoring, single averaged ECGs in the time,frequency and spatial domains and a variety of stressrecoding methods, have been devised. The cardiologist,at least, must understand the application and value of these important clinical investigations. This chapterdeals comprehensively with 12-lead electrocardiographyand the major pathophysiological conditions that canbe revealed using this technique. Cardiac arrhythmiasand other information from ambulatory and averagingtechniques are explained only briefly but are more fullycovered in other chapters, for example those devoted tospecific cardiac arrhythmias.
Introduction
Broadly speaking, electrocardiography, i.e. the science andpractice of making and interpreting recordings of cardiacelectrical activity, can be divided into morphology andarrhythmology. While electrocardiographic morphologydeals with interpretation of the shape (amplitude, widthand contour) of the electrocardiographic signals, arrhyth-mology is devoted to the study of the rhythm (sequenceand frequency) of the heart. Although these two parts of electrocardiography are closely interlinked, their metho-dological distinction is appropriate. Intentionally, thischapter covers only electrocardiographic morphologysince rhythm abnormalities are dealt with elsewhere inthis book.
Morphology of the ECG
The electrocardiogram (ECG), introduced into clinicalpractice more than 100 years ago by Einthoven, comprisesa linear recording of cardiac electrical activity as it occursover time. An atrial depolarization wave (P wave), aventricular depolarization wave (QRS complex) and aventricular repolarization wave (T wave) are successively
1
TETC01 12/2/05 18:09 Page 1
 
2
Chapter 1
recorded for each cardiac cycle (Fig. 1.1). During normalsinus rhythm the sequence is always P–QRS–T. Depend-ing on heart rate and rhythm, the interval betweenwaves of one cycle and another is variable.
Electrophysiological principles
[1–6]The origin of ECG morphology may be explained by thedipole-vector theory, which states that the ECG is anexpression of the electro-ionic changes generated duringmyocardial depolarization and repolarization. A pair of electrical charges, termed a dipole, is formed during bothdepolarization and repolarization processes (Fig. 1.2).These dipoles have a vectorial expression, with the headof the vector located at the positive pole of a dipole.
PR intervalQRSSTsegmentPRsegmentST intervalT waveP waveQT interval
Figure 1.1
ECG morphology recordedin a lead facing the left ventricular freewall showing the different waves andintervals. Shading, atrial repolarizationwave.
Cell membraneOutsideInt. cel.Sarc.Ret.
Na023STT1KKKDepolarizationdipole
Ca
 
 
 
 
 
+ + + + + +
NaNaNa
Ca
 
 
 
 
 
++ + + + + –
Na
 
 
+ + + ++ +
 
 
 
 
Na
+
Na
+
Na
+
K
+
Na
+
Ca
2+
Ca
2+
Ca
2+
Ca
2+
Na
+
Ca
AB
K
K
+
K
+
 
 
 
 
 
+ + + + + +
Na
Ca
+ + +
 
 
 
 
 
– + + +
NaCa
+ + + + + –
 
 
 
 
 
+
NaCa
 
 
 
 
 
+ + + + + +
Ca
 
 
 
 
 
+ + + + + +
+ + + + + + + + + + + + + + + + + +
 
+
Repolarizationdipole
+
 
Direction of phenomenon Vector Dipole
 
+
 
   I  o  n   i  c  p  u  m  p
K
Figure 1.2
Scheme of electro-ionicchanges that occur in the cellulardepolarization and repolarization in thecontractile myocardium. (A) Curve of action potential. (B) Curve of theelectrogram of a single cell (repolarizationwith a dotted line) or left ventricle(normal curve of ECG with a positivecontinuous line). In phase 0 of actionpotential coinciding with the Na
+
entrance, the depolarization dipole (
−+
)and, in phase 2 with the K
+
exit, therepolarization dipole (
+−
), are originated.At the end of phase 3 of the actionpotential an electrical but not ionicbalance is obtained. For ionic balancean active mechanism (ionic pump)is necessary.
An electrode that faces the head of the vector records apositive deflection.To ascertain the direction of a wavefront, the ECG isrecorded from different sites, termed ‘leads’. When record-ing the 12-lead ECG six frontal leads (I, II, III, aVR, aVL,aVF) and six horizontal leads (V1–V6) are used. Thereare three bipolar leads in the frontal plane that connectthe left to right arm (I), the left leg to right arm (II) and theleft leg to left arm (III). According to Einthoven’s law, thevoltage in each lead should fit the equation II
=
I
+
III.These three leads form Einthoven’s triangle (Fig. 1.3A).Bailey obtained a reference figure (Bailey’s triaxial sys-tem) by shifting the three leads towards the centre.There are also three augmented bipolar leads (aVR, aVLand aVF) in the frontal plane (Fig. 1.3B). These are de-
TETC01 12/2/05 18:09 Page 2
 
scribed as ‘augmented’ because, according to Einthoven’slaw, their voltage is higher than that of the simple bipolarleads. By adding these three leads to Bailey’s triaxial sys-tem, Bailey’s hexaxial system is obtained (Fig. 1.3C). Inthe horizontal plane, there are six unipolar leads (V1–V6)(Fig. 1.3D).One approach to understanding ECG morphology isbased on the concept that the action potential of a cellor the left ventricle (considered as a huge cell thatcontributes to the human ECG) is equal to the sum of subendocardial and subepicardial action potentials. Howthis occurs is shown in Fig. 1.4. This concept is useful forunderstanding how the ECG patterns of ischaemia andinjury are generated (see Fig. 1.17).
Normal characteristics
Heart rate
Normal sinus rhythm at rest is usually said to rangefrom 60 to 100 b.p.m. but the nocturnal sleeping heartrate may fall to about 50 b.p.m. and the normal day-time resting heart rate rarely exceeds 90 b.p.m. Severalmethods exist to assess heart rate from the ECG. With thestandard recording speed of 25 mm/s, the most commonmethod is to divide 300 by the number of 5-mm spaces(the graph paper is divided into 1- and 5-mm squares)between two consecutive R waves (two spaces represents150 b.p.m., three spaces 100 b.p.m., four spaces 75 b.p.m.,five spaces 60 b.p.m., etc.).
Rhythm
The cardiac rhythm can be normal sinus rhythm (emanat-ing from the sinus node) or an ectopic rhythm (from asite other than the sinus node). Sinus rhythm is con-sidered to be present when the P wave is positive in I, II,aVF and V2–V6, positive or biphasic (
+
/–) in III and V1,positive or –/
+
in aVL, and negative in aVR.
PR interval and segment
The PR interval is the distance from the beginning of theP wave to the beginning of the QRS complex (Fig. 1.1).The normal PR interval in adult individuals ranges from
The Morphology of the Electrocardiogram
3
 V 
4
R V 
3
R V 
1
+++IIIIIIIIIIII
BCD
+++
+VR
 A
+VL+I+II+VF+III+
–180º–150º–120º–60º–30º+30º+60º+90º+120º+150º V 
6
 V 
7
 V 
4
 V 
4
 V 
3
 V 
2
Figure 1.3
(A) Einthoven’s triangle. (B) Einthoven’s triangle superimposed on a human thorax. Note the positive (continuous line) andnegative (dotted line) part of each lead. (C) Bailey’s hexaxial system. (D) Sites where positive poles of the six precordial leads are located.
 A ABBLV 
Figure 1.4
Correlation between global action potential, i.e.the sum of all relevant action potentials, of the subendocardial(A) and subepicardial (B) parts of the left ventricle and the ECGwaveform. Depolarization starts first in the furthest zone(subendocardium) and repolarization ends last in the furthestzone (subendocardium). When the global action potential of the nearest zone is ‘subtracted’ from that of the furthest zone,the ECG pattern results. (LV
=
left ventricle.)
TETC01 12/2/05 18:09 Page 3

Activity (28)

You've already reviewed this. Edit your review.
1 hundred reads
1 thousand reads
dr9348345000 liked this
ramanrajesh83 liked this
byounis liked this
Soe Dardjo liked this
Sunil Bali liked this
senthil8 liked this
phng77 liked this
drlebinh liked this

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->