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5 Steps to Rhythm Strip Interpretation

© 2003 Ed4Nurses, Inc.


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David W. Woodruff, MSN, RN, CNS, CCRN

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5 Steps to Rhythm Strip Interpretation
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5 Steps to Rhythm Strip Interpretation


As patient acuity increases, more patients are being placed on telemetry and
nurses are being expected to be able to read EKG rhythm strips. However, this skill need
not be difficult to learn. It is best accomplished by a systematic method of analysis. The
5 Steps to Rhythm Strip Interpretation systematically reviews the major components of a
rhythm strip to help determine the type of rhythm and the appropriate course of
treatment. The 5 Steps are listed below:

Step 1. Is the speed of the rhythm between 60-100?


Step 2. Is it regular?
Step 3. Is the complex narrow?
Step 4. Is it preceded by a P-wave?
Step 5. Do all the complexes look the same?

Step 1 evaluates the speed of the rhythm to determine if it is normal, too slow or too fast.
A speed between 60-100 maintains the best hemodynamic stability. Rates less than 60 or
greater than 100, can lead to hemodynamic instability and become symptomatic.

Step 2 asks if the rhythm is regular. Rhythms originating from the normal pacemakers in
the heart will be regular. Irregular rhythms indicate extra beats or abnormal rhythms.

Step3 assesses the shape of the complex. A narrow complex is normal. A wide complex
indicates conduction abnormalities.

Step 4 asks if a P-wave precedes the QRS complex. This represents normal conduction
from the atria to the ventricles. If the P-wave is absent, the impulse is being generated
from elsewhere in the heart.

Step 5 assesses whether all the complexes look the same. Normal conduction follows the
same pathway with each beat. Different looking complexes indicate the some impulses
are following alternative or aberrant pathways.

If the nurse can answer all of the questions asked by the 5-steps affirmatively, the
patient has a sinus rhythm. The greater the number of questions answered negatively,
then the greater the abnormal conduction through the heart. This usually indicates
myocardial irritability.

Spend a few moments to reacquaint yourself with the normal EKG complex, and
its components.

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Normal conduction
Depolarization:
Impulses begin at the Sinoatrial (SA) node, generating a P-wave. The impulse travels
through the electrical pathways to the Atrio-Ventricular (AV) node. The AV node delays
the impulse, so that the atria and ventricles don’t fire at the same time. The delay is seen
on the EKG as the P-R interval. As the impulse travels down the perkinge fibers in the
ventricles, it generates the QRS complex.

Repolarization:
In order for the heart to fire again, it needs to re-load. Electrical re-loading of the heart is
called repolarization and is represented by the T-wave on the EKG.

Figure 1

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The EKG Complex:
Keep in mind that the EKG complex represents electrical activity of the heart and
does not assure mechanical activity (contraction). Loss of contraction associated with
continued electrical activity is called “pulseless electrical activity” (PEA).

How an EKG is obtained


An EKG machine is a voltmeter. In other words, it reads electrical energy from
the body. The heart uses electrical energy to cause muscle cells to contract. By reading
the electrical energy of the heart, the nurse can tell if it is generated and conducted
correctly.
An EKG is obtained by placing electrical sensors (leads) on the patient’s chest.
Usually 12 leads are used to look at the heart from many angles. The EKG machine
doesn’t look at all 12 leads at once; instead it chooses one at a time to view, and each
view we call a lead on the resulting tracing.

What do all the different leads mean?


The EKG machine looks at only one sensor (lead) at a time, but will use another
as a ground. This gives the machine perspective for its view. To understand this
concept, think of the process of taking a picture with a camera. Where you stand to take
the picture is equally as important as what direction you face when taking it. The EKG
machine “takes pictures” of the heart. By using different leads, the machine can change
its view or perspective on the heart. The EKG
machine “looks” from the positive (+) lead to
the negative (-) lead. In figure 2, the EKG
machine will be looking in the direction of the
arrow.

Why do we need all those different


leads?
Each lead looks from a different
perspective, and gives a different view of the
heart. Using different leads allows the nurse to
watch electrical activity in many different parts
of the heart.

What lead does my monitor at work Figure 2


use?
To identify which lead your monitor is reading, look at the lead selection dial or
on an EKG tracing. The lead will be identified by its abbreviation. For example, II
indicates lead II, V1 indicates the first chest lead.

The EKG and the patient


If a washing machine is not working, then an appliance repairman might be called
to attempt to repair it. He would hook up a voltmeter to determine if it’s “got power.”
Even if it’s powered up, it may not work. The motor or a relay may be broken.

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An EKG is helpful in the same way. The EKG tracing indicates electrical activity
of the heart. Usually normal EKG activity will correlate with normal mechanical activity
(cardiac output). However, it is possible that the patient can have normal EKG activity
and be hemodynamically unstable.
Keep in mind that the EKG only represents the electrical activity of the heart and
does not measure mechanical activity. The blood pressure can be measured to assess
mechanical activity (cardiac output). There is no direct correlation between the type of
EKG rhythm and the blood pressure. A heart rate of 50 may be perfectly normal for one
patient, and another would be in shock with the same heart rate. Blood pressure
determines whether a rhythm is stable.

Validating EKGs
Sometimes a wire is cracked, or the lead is dried up and a poor connection is
made. In these situations the EKG machine may not be able to read accurately.
Whenever possible, the EKG should be validated by checking it in more than one lead.
This is usually a simple procedure of turning the lead selector dial to another lead. Most
monitoring floors have policies about which lead is suppose to be monitored, so
remember to turn the lead selector back to its original position.

Measuring intervals
The duration of the waveforms on the EKG should be short. To assess for
changes, the intervals can be measured. There are two measurements that we will use
with the 5-steps: the PR-interval, and the QRS duration. These are the most helpful in
analyzing rhythm strips.
Intervals can be measured by comparing the distance on the tracing to the
markings on the EKG paper. The EKG paper is marked in time. Each small box
represents 0.04 seconds, and each large box represents 0.20 seconds. A large box
contains five small boxes, see figure 3.

Figure 3
There are 30 large boxes in each six-second strip. Fortunately, the tracing will be
marked with hash-marks at the top to designate each six-second increment. Using a six-
second strip is helpful in determining heart rate. Count the number of complexes in six
seconds and multiply it by ten for the heart rate per minute.

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The PR-interval is the distance between the beginning of the P-wave and the
beginning of the QRS complex. The purpose of measuring the PR-interval is to
determine if the impulse from the SA node is conducted to the ventricles through the
normal conduction pathways. Figure 4 shows where to measure the PR-interval.

Figure 4
The normal PR-interval is 0.12 to 0.20 seconds. Longer intervals indicate
slowing of the impulse in the AV-node.
The QRS duration indicates how long it takes for the impulse to travel through the
ventricles. The QRS duration is measured at the beginning of the QRS complex until the
end of the complex (figure 5). A normal QRS duration is 0.04-0.08 seconds.

Figure 5
QRS duration determines whether we have a narrow complex or not. Wide
complexes are associated with aberrant conduction, or ventricular rhythms.

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Identifying normal rhythms


Sinus Rhythm
A heart rhythm that originates in the sinoatrial node and is normally conducted is
called a Normal Sinus Rhythm (NSR). The characteristics of a normal sinus rhythm are a
regular rate between 60-100 beats per minute, a narrow complex, preceded by a P-wave
where all the complexes look the same.
Normal conduction indicates that the myocardium is not irritable or injured. The real
test to determine whether a patient is hemodynamically stable is to check his blood
pressure. So, vital signs should be taken.
Use the 5-Step approach to identify the rhythm:
Step 1. Rate: 60-100
Step 2. Regular
Step 3. P-wave precedes QRS (PR interval 0.16 sec)
Step 4. Narrow complex (QRS duration 0.06 seconds)
Step 5. All complexes look the same

All five questions were answered with a “yes”; therefore this is a normal sinus
rhythm. A normal sinus rhythm is usually associated with normal hemodynamics, but the
blood pressure should be taken to validate stability. There is no treatment necessary if
the patient’s blood pressure is normal.

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Sinus Tachycardia
A rhythm that originates in the SA node and is conducted normally, but that
exceeded 100 beats-per-minute is called Sinus Tachycardia (ST). Use the 5-Steps to
identify the rhythm below:
Step 1. Rate: >100
Step 2. Regular
Step 3. P-wave precedes QRS (PR interval 0.12)
Step 4. Narrow complex (QRS duration 0.04 seconds)
Step 5. All complexes look the same

Four of the five questions were answered affirmatively. The only negative
answer was for the rate. This is a sinus rhythm (has a P-wave), it is just too fast. The rate
in the above strip is approximately 120. You will see the rate displayed on your monitor,
or you can estimate it by counting the number of QRS complexes on a six-second strip.
The above strip is cut off prematurely, so the rate from the monitor will be used.
Sinus tachycardia is caused by fever, anxiety, pain, dehydration, or hypoxemia.
Treatment would be for the underlying condition.

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Sinus Bradycardia
A rhythm that originates in the SA node (P-wave) but is less than 60 beats per
minute is called Sinus Bradycardia (SB). To summarize the findings from the 5-step
analysis:
Step 1. Rate: <60
Step 2. Regular
Step 3. P-wave precedes QRS (PR interval 0.16 seconds)
Step 4. Narrow complex (QRS duration 0.04 seconds)
Step 5. All complexes look the same

The only question answered negatively was for the rate. The rate for this strip is
about 40. This rhythm is not showing a lot of myocardial irritability, but slow rates can
lead to hypotension. Therefore, the blood pressure should be taken. Some patients, like
athletes, normally have a sinus bradycardia. Calcium-channel blocker and beta-blocker
medications can cause bradycardia. Assess your patient to see if he takes these
medications.
If the blood pressure is low, then treatment would include administration of
atropine or epinephrine. Persistent rhythms may require a pacemaker.

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Identifying abnormal rhythms


Atrial Flutter
The rhythm strip below has a regular ventricular rhythm, but has a saw-tooth wave
preceding the QRS instead of a P-wave. Note the difference in morphology between a
rounded P-wave and the sharp, saw-tooth flutter waves (F-waves). This pattern is
consistent with atrial flutter. Using the 5-step analysis, our findings would be:
Step 1. Rate: 60-150
Step 2. Regular
Step 3. Several F-waves precede QRS
Step 4. Narrow complex (QRS duration 0.12)
Step 5. All complexes look the same

In step 3 the flutter wave was discovered so that atrial flutter could be diagnosed.
In the strip above, the ventricular rate (QRS) is relatively slow at 60 beats per minute.
There are three flutter (F-waves) for every QRS complex, a 1:3 ratio. If every flutter
wave were conducted, the ventricular rate would increase to 180 and the patient would
probably develop hypotension. Always check the blood pressure to assess the patient’s
stability.
Treatment with digoxin, verapamil, or diltiazem would help to slow the
ventricular rate. Amiodarone, sotalol, or flecainide would be used to chemically convert
the rhythm back to sinus rhythm.

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Atrial Fibrillation
In the following rhythm, a P-wave is lacking again. However, no F-waves are
present. Instead, there is a wavy or “noisy” baseline. This is consistent with fibrillation
waves (f-waves). Using our 5-steps atrial fibrillation (A-fib) can be identified.
a. Rate: 70 (can be abnormal with a-fib)
b. Irregular
c. Several f-waves precede QRS
d. Narrow complex (QRS duration 0.08 seconds)
e. All complexes look the same

The hallmark of atrial fibrillation is an irregularly-irregular rhythm. There is no


pattern to the irregularity. This happens because of an irregular pattern of atrial impulses
conducting to the ventricles.
Treatment for atrial fibrillation would be to control the rate from becoming too
fast with digoxin, verapamil, diltiazem, or to convert it back to sinus rhythm with
cardioversion, or chemically with amiodarone, sotalol, flecainide. If the patient has
persistent atrial fibrillation he should be anticoagulated to prevent blood clots from
developing in the atria.

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Supraventricular Tachycardia
A very fast, but regular rhythm with a narrow complex is called supraventricular
tachycardia (SVT). It is referred to as supraventricular because it is too fast to see P-
waves, and may be coming from somewhere other than the SA-node.
The 5-steps will identify this rhythm as a very fast, regular rhythm with a narrow
complex.
Step 1. Rate: 140-300
Step 2. Regular
Step 3. P-wave may precede QRS
Step 4. Narrow complex (QRS duration 0.04 seconds)
Step 5. All complexes look the same

The rate in this strip is about 260. Rates exceeding 150 are often accompanied by
hypotension, due to inadequate diastolic time for ventricular filling.
Therefore, treatment is necessary and includes vagal maneuvers, adenosine, beta-
blockers, verapamil, or cardioversion.

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Junctional Rhythm
A rhythm originating in the AV-node is called a junctional rhythm. The characteristic
signs are a slow rhythm without a P-wave. The 5-steps would identify the following
characteristics:
Step 1. Rate: 40-60 (accelerated 60-100)
Step 2. Regular
Step 3. P-wave absent or inverted
Step 4. Narrow complex (QRS duration 0.06 seconds)
Step 5. All complexes look the same

In a junctional rhythm the P-wave may be inverted and very close to the QRS because
it is being generated by the AV node, or it may be absent entirely. The rate in this strip is
50; the blood pressure should be assessed to determine stability. Symptomatic junctional
rhythms are treated with atropine or a pacemaker.

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First-degree AV-Block
The AV node can function as a pacemaker in junctional rhythms as well as act to
delay the impulse from the SA-node, so that the atria and ventricles don’t contract at the
same time. Sometimes the AV-node may delay the impulse too long and this is called a
first-degree AV-block. Our 5-step analysis will identify the following characteristics:
Step 1. Rate: 60-100
Step 2. Regular
Step 3. P-wave precedes QRS: long PR-interval (0.38 seconds)
Step 4. Narrow complex (QRS duration 0.06 seconds)
Step 5. All complexes look the same

As long as the blood pressure is normal, treatment is not necessary. It is important to


observe the patient for development of a greater degree of AV blockage. A first-degree
block can progress to a second-degree or third-degree block.

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Second-degree AV-Block
A greater degree of AV blockage is called a second-degree block. The cardinal signs
are that the rhythm is irregular and that more than one P-wave precedes the QRS. Notice
in the strip below that there is a long space between the second and third complexes, with
one P-wave immediately after the T-wave and another preceding the third QRS complex.
Using the 5-stap method, the following characteristics are identified:
Step 1. Rate: varies
Step 2. Irregular
Step 3. P-wave precedes QRS (PR interval varies)
Step 4. Narrow complex, but some dropped (QRS duration 0.08 seconds)
Step 5. All complexes look the same

Again, the blood pressure should be assessed to determine if the patient is stable.
Digoxin can cause this rhythm and should be discontinued. A pacemaker may be
necessary if the rate is slow and the blood pressure drops.

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Mobitz Type I Block


Another type of second-degree block is called Mobitz Type I, or Wenckebach. In this
type of block the PR-interval becomes progressively longer, until a QRS complex is
dropped. In the strip below, notice how the PR-interval is long in the first complex (0.32
seconds) and longer yet in the second (0.42 seconds). A P-wave is in the T-wave of the
second complex and a third complex is not conducted causing the delay between complex
two and complex three. The characteristics of a Mobitz Type I second-degree block can
be found in the 5-step analysis:
Step 1. Rate: varies
Step 2. Irregular
Step 3. P-wave precedes QRS: PR-interval becomes progressively longer, until a
QRS is dropped.
Step 4. Narrow complex (QRS duration 0.10 seconds)
Step 5. All complexes look the same

Digoxin can slow conduction through the AV-node and cause this type of block.
Therefore digoxin should be held. Atropine or a pacemaker will be necessary if the
patient is symptomatic, so check the blood pressure.

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Third-degree AV-Block
Loss of all communication between the atria and ventricles is called a third-degree
AV-block. P-waves will be regular and flow through the strip, but they are not conducted
to the ventricles and there is no relationship between the P-wave and the QRS complex.
The QRS complex is originating in the ventricle and typically has a very slow rate. The
5-step analysis would identify the following characteristics:
Step 1. Rate: <60
Step 2. Regular
Step 3. No coordination between P-wave and QRS
Step 4. Wide complex (QRS duration 0.16 seconds)
Step 5. All complexes look the same

The patient will probably be symptomatic due to the slow ventricular response
and loss of the atrial kick. The atria may be contracting (P-wave present), but are not
coordinated with the ventricles (QRS).
Treatment includes administering atropine, but a pacemaker may be required to
increase the heart rate. Be prepared to administer ACLS if the patient
decompensates.

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Ventricular Tachycardia
A rapid rate that comes from the ventricles is called ventricular tachycardia (V-
tach). The rhythm will be fast (>100 beats per minute), regular, and have a wide QRS
complex. The 5-step analysis would identify:
Step 1. Rate: 100-220
Step 2. Regular
Step 3. No P-waves
Step 4. Wide complex (QRS duration 0.12 seconds)
Step 5. All complexes look the same

Treatment depends on whether there is a pulse. If the patient has a pulse and a
stable blood pressure the rhythm will be converted using medications. Lidocaine,
amiodarone, procainamide, and sotalol are used to convert v-tach. If the patient has a
pulse, but the blood pressure is unstable then cardioversion is performed and followed by
lidocaine, or procainamide.
If the patient does not have a pulse, call a code! Treatment includes immediate
defibrillation, cardiopulmonary resuscitation, and administration of epinephrine.

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Ventricular Fibrillation
Loss of all coordinated activity of the heart results in ventricular fibrillation (V-fib).
The rhythm strip will show a saw-tooth, or wavy pattern to the baseline without QRS
complexes. Characteristics from the 5-step analysis include:
Step 1. Rate: none detectable
Step 2. Irregular
Step 3. No P-wave or QRS
Step 4. Wide, bizarre, chaotic complexes
Step 5. Complexes look different

There is no coordinated activity of the heart during V-fib, and the patient will have no
pulse or blood pressure. Immediate treatment with defibrillation is associated with
improved outcomes. If defibrillation does not convert the patient back to a stable rhythm,
then cardiopulmonary resuscitation should be started and epinephrine should be
administered. Lidocaine, amiodarone, procainamide, or magnesium may be helpful
pharmacologic agents to convert V-fib.

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Asystole
No electrical activity of the heart is called asystole. The EKG strip will show a flat-
line, as illustrated in the strip below. A flat-line EKG strip can also be obtained if the
lead wires are not properly connected, therefore asystole should be confirmed in two
leads. Turn the dial on your monitor to a different lead to confirm asystole. The
characteristics of asystole are:
Step 1. Rate: none
Step 2. Flat line
Step 3. P-waves may be present
Step 4. QRS complexes absent
Step 5. No electrical or mechanical activity

Loss of electrical activity corresponds to loss of mechanical activity. This patient


will have neither pulse nor blood pressure. Cardiopulmonary resuscitation should be
started at once, followed by epinephrine and atropine. A pacemaker may also be helpful
in stimulating contraction.

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Pulseless Electrical Activity


When there is electrical activity of the heart, but no mechanical activity, there will be
no pulse or blood pressure. This phenomenon is called pulseless electrical activity
(PEA). Any type of EKG rhythm could be present. However, it is often a ventricular
rhythm. In PEA there is electrical activity of the heart but no mechanical activity. The
EKG will look OK, but there is no pulse. PEA can be caused by compression of the heart
by fluid. This happens in cardiac tamponade, tension pneumothorax, and chest trauma.
The characteristics from our 5-step analysis will show:
Step 1. Rate: varies
Step 2. May be regular or irregular
Step 3. P-waves may be present
Step 4. QRS complex present
Step 5. No detectable pulse or B/P with electrical activity

Treatment is necessary because there is no mechanical activity and therefore no


pulse or blood pressure. Immediate cardiopulmonary resuscitation, followed by
administration of epinephrine and atropine is the treatment of choice. It is also important
to correct the mechanical cause. If the patient has cardiac tamponade, CPR and
medications will not deliver a stable blood pressure until the tamponade is corrected.

Summary
The 5-steps to Rhythm Strip Interpretation is a simple and accurate system to help
you rapidly identify abnormal rhythm strips. Practice using the system on every strip you
can. That way the abnormal findings will really stand out when you see them.
Treatment of any abnormal rhythm depends on whether the patient is
symptomatic. Monitor his blood pressure to find out. Even with an abnormal rhythm he
may still maintain his perfusion and no treatment will be immediately necessary. Be sure
to notify the physician of any changes in cardiac rhythm, though.

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Post-test
1. EKG rhythms with a rate of greater than 100 or less than 60 may be associated
with:
a. Hypertension
b. Hyperkalemia
c. Hypotension
d. Hypokalemia

2. A wide QRS complex indicates:


a. Normal conduction
b. Rapid conduction
c. Slowed conduction
d. No conduction

3. Why is it important that all the QRS complexes look the same?
a. Indicates conduction through normal pathways
b. Indicates conduction through pacemakers
c. Indicates that the monitor is working
d. Indicates abnormal conduction

4. A normal PR-interval is:


a. 0.02 seconds
b. 0.18 seconds
c. 0.22 seconds
d. 6 seconds

5. In sinus tachycardia which of the following variables is abnormal?


a. Rhythm
b. Shape of complex
c. PR interval
d. Rate

6. A first-degree heart block may result in:


a. Long QRS duration
b. Fast rate
c. Missed beats
d. Long PR interval

7. The primary characteristic of supraventricular tachycardia (SVT) that makes it


unstable is:
a. Rhythm
b. Rate
c. Shape of complex
d. PR interval

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8. Initial emergent treatment for ventricular fibrillation is:
a. Defibrillation
b. Epinephrine
c. CPR
d. Lidocaine

9. A flat-line on the monitor may be asystole. What common complication can


imitate asystole on the monitor?
a. Unplugged monitor
b. Wrong lead selected
c. Disconnected lead
d. Dead battery in monitor

10. The condition that will result in a EKG rhythm on the monitor, but no pulse or
blood pressure is called:
a. Asystole
b. Third-degree block
c. Ventricular fibrillation (VF)
d. Pulseless electrical activity (PEA)

Answers:
1. c
2. c
3. a
4. b
5. d
6. a
7. b
8. a
9. c.
10. d

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Additional Resources

Book:
McPhee, A. T. (1997). ECG interpretation made incredibly easy. Springhouse:
Springhouse.

On-line:
The EKG Site: http://www.the-ekg-site.com. Accessed February 22, 2004.
EKG rounds: http://www.mdchoice.com/ekg/ekg.asp. Accessed January 6, 2004.
EKG presentation:
http://physioweb.med.uvm.edu/cardiacep/CardiacEP2003_files/frame.htm. Accessed
January 6, 2004.

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