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Electrocardiography (ECG or EKG) is the recording of the electrical activity of the heart over time via skin electrodes. It is a noninvasive recording produced by an electrocardiographic device. The etymology of the word is derived from electro, because it is related to electrical activity, cardio, Greek for heart, graph, a Greek root meaning "to write". Electrical impulses in the heart originate in the sinoatrial node and travel through the intrinsic conducting system to the heart muscle.The impulses stimulate the myocardial muscle fibres to contract and thus induce systole. The electrical waves can be measured at selectively placed electrodes (electrical contacts) on the skin. Electrodes on different sides of the heart measure the activity of different parts of the heart muscle. An ECG displays the voltage between pairs of these electrodes, and the muscle activity that they measure, from different directions, also understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle. It is the best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by levels of dissolved salts (electrolytes), such as potassium, that are too high or low. In myocardial infarction (MI), the ECG can identify damaged heart muscle. But it can only identify damage to muscle in certain areas, so it can't rule out damage in other areas. The ECG cannot reliably measure the pumping ability of the heart; for which ultrasound-based (echocardiography) or nuclear medicine tests are used. History Alexander Birmick Muirhead is reported to have attached wires to a feverish patient's wrist to obtain a record of the patient's heartbeat while studying for his Doctor of Science (in electricity) in 1872 at St Bartholomew's Hospital. This activity was directly recorded and visualized using a Lippmann capillary electrometer by the British physiologist John Burdon Sanderson. The first to systematically approach the heart from an electrical point-of-view was Augustus Waller, working in St Mary's Hospital in Paddington, London. His electrocardiograph machine consisted of a Lippmann capillary electrometer fixed to a projector. The trace from the heartbeat was projected onto a photographic plate which was itself fixed to a toy train. This allowed a heartbeat to be recorded in real time. In 1911 he still saw little clinical application for his work. An initial breakthrough came when Willem Einthoven, working in Leiden, The Netherlands, used the string galvanometer that he invented in 1903. This device was much more sensitive than both the capillary electrometer that Waller used and the string galvanometer that had been invented separately in 1897 by the French engineer Clément Ader.
usually with very sticky circles of thick tape-like material (the electrode is embedded in the center of this circle). Placement of electrodes Ten electrodes are used for a 12-lead ECG. and complexes displayed on the ECG. there have been many advances in electrocardiography over the years. In 1924. ELECTRODE LABEL (in the ELECTRODE PLACEMENT USA) RA On the right arm. avoiding bony prominences. In electrocardiography. depolarization wavefronts (or mean electrical vectors). but on the left arm this time. R. avoiding bony prominences. The instrumentation. In the fourth intercostal space (between ribs 4 & 5) to the left of the V2 sternum. Note that the limb electrodes can be far down on the limbs or close to the hips/shoulders. but on the right leg. These electrodes are attached to the patient's body.Einthoven assigned the letters P. the word. and described the electrocardiographic features of a number of cardiovascular disorders. V4 In the fifth intercostal space (between ribs 5 & 6) in the midclavicular . They are labeled and placed on the patient's body as follows: Proper placement of the limb electrodes. V3 Between leads V2 and V4. but they must be even (left vs. LA In the same location that RA was placed. has evolved from a cumbersome laboratory apparatus to compact electronic systems that often include computerized interpretation of the electrocardiogram. "lead" (rhymes with 'speed') refers to the signal that goes between two electrodes. he was awarded the Nobel Prize in Medicine for his discovery. right). color coded as recommended by the American Health Association. ECG leads record the electrical signals of the heart from a particular combination of recording electrodes which are placed at specific points on the patient's body. S and T to the various deflections. for example. In the fourth intercostal space (between ribs 4 & 5) to the right of the V1 sternum (breastbone). Q. Leads Graphic showing the relationship between positive electrodes. Though the basic principles of that era are still in use today. LL On the left leg. RL In the same place that LL was positioned.
III. and spreads from the right atrium to the left atrium. and inverted in aVR (since it is going away from the positive electrode for that lead). . which is upright in II. but in the anterior axillary line. • • The relationship between P waves and QRS complexes helps distinguish various cardiac arrhythmias. a QRS complex and a T wave. A small U wave is normally visible in 50 to 75% of ECGs. and aVF (since the general electrical activity is going toward the positive electrode in those leads). (The anterior axillary line is the imaginary line that runs down from the point midway between the middle of the clavicle and the lateral end of the clavicle. The baseline voltage of the electrocardiogram is known as the isoelectric line. (The midaxillary line is the imaginary line that extends down from the middle of the patient's armpit. the main electrical vector is directed from the SA node towards the AV node. The shape and duration of the P waves may indicate atrial enlargement. The four deflections were originally named ABCDE but renamed PQRST after correction for artifacts introduced by early amplifiers. Horizontally even with V4.  P wave During normal atrial depolarization. A P wave must be upright in leads II and aVF and inverted in lead aVR to designate a cardiac rhythm as Sinus Rhythm.) Waves and intervals Schematic representation of normal ECG A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave. This turns into the P wave on the ECG. the lateral end of the collarbone is the end closer to the arm. Typically the isoelectric line is measured as the portion of the tracing following the T wave and preceding the next P wave.) Horizontally even with V4 and V5 in the midaxillary line.V5 V6 line (the imaginary line that extends down from the midpoint of the clavicle (collarbone).
In addition. represent depolarization of the interventricular septum. correct interpretation of difficult ECGs requires exact labeling of the various waves. the QRS complex is larger than the P wave. depending on the relative size of each wave. QRS complex The QRS complex is a structure on the ECG that corresponds to the depolarization of the ventricles.04 sec (40 ms) in duration. myocardial infarction. electrolyte derangements. but any abnormality of conduction takes longer. On an ECG tracing. and causes widened QRS complexes. and can be appreciated in the lateral leads I. and morphology of the QRS complex is useful in diagnosing cardiac arrhythmias. an Rs complex would be positively deflected. • The duration. Q waves can be normal (physiological) or pathological. an R wave. For example. when present. it would be impossible to appreciate this distinction without viewing the actual ECG. V5 and V6. this corresponds to . It is far smaller in magnitude than the QRS and is therefore obscured by it. Q waves greater than 1/4 the height of the R wave. Some authors use lowercase and capital letters. If both complexes were labeled RS. and other disease states. and may represent myocardial infarction. By convention. ventricular hypertrophy. A saw tooth formed P wave may indicate atrial flutter.04 seconds. It is usually 120 to 200 ms long. However. which resembles an inverse P wave. the QRS complex tends to look "spiked" rather than rounded due to the increase in conduction velocity. "Buried" inside the QRS wave is the atrial repolarization wave. they are referred to as septal Q waves. while a rS complex would be negatively deflected. greater than 0. any combination of these waves can be referred to as a QRS complex. amplitude.• • Absence of the P wave may indicate atrial fibrillation. Pathological Q waves refer to Q waves that have a height of 25% or more than that of the partner R wave and/or have a width of greater than 0.08 to 0. because the His/Purkinje system coordinates the depolarization of the ventricles. Not every QRS complex contains a Q wave. A normal QRS complex is 0.12 sec (80 to 120 ms) in duration represented by three small squares or less. • • • PR/PQ interval The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. conduction abnormalities. or in the right precordial leads are considered to be abnormal. Because the ventricles contain more muscle mass than the atria. For this reason. aVL. Normal Q waves. and an S wave.
The typical ST segment duration is usually around 0. This measure has a false positive rate of 15-20% (which is slightly higher in women than men) and a false negative rate of 20-30%.12 sec (80 to 120 ms). It starts at the J point (junction between the QRS complex and ST segment) and ends at the beginning of the T wave. it is not uncommon to have an isolated negative T wave in lead III.08 to 0. . Variable morphologies of P waves in a single ECG lead is suggestive of an ectopic pacemaker rhythm such as wandering pacemaker or multifocal atrial tachycardia ST segment Main article: Myocardial infarction The ST segment connects the QRS complex and the T wave and has a duration of 0. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the absolute refractory period. In case a Q wave was measured with a ECG the PR interval is also commonly named PQ interval instead. aVL. However. In addition. In most leads. or biphasic T wave. such as seen in WolffParkinson-White syndrome. since it is usually difficult to determine exactly where the ST segment ends and the T wave begins. ST segment elevation may indicate myocardial infarction. the T wave is positive. downsloping. or depressed ST segments may indicate coronary ischemia. a negative T wave is normal in lead aVR. or aVF. Lead V1 may have a positive. • • • The normal ST segment has a slight upward concavity. However. • • • • • A PR interval of over 200 ms may indicate a first degree heart block. negative. The last half of the T wave is referred to as the relative refractory period (or vulnerable period).08 sec (80 ms). PR segment depression may indicate atrial injury or pericarditis. T wave The T wave represents the repolarization (or recovery) of the ventricles. A short PR interval may indicate a pre-excitation syndrome via an accessory pathway that leads to early activation of the ventricles. An elevation of >1mm and longer than 80 milliseconds following the J-point. A variable PR interval may indicate other types of heart block.3 to 5 small boxes. Flat. It should be essentially level with the PR and TP segment. the relationship between the RT segment and T wave should be examined together.
Long QT intervals may also be induced by antiarrythmic agents that block potassium channels in the cardiac myocyte. and various correction factors have been developed to correct the QT interval for the heart rate. The earliest electrocardiographic finding of acute myocardial infarction is sometimes the hyperacute T wave.g. most evident in lead V3. The QT interval as well as the corrected QT interval are important in the diagnosis of long QT syndrome and short QT syndrome.• • • • Inverted (or negative) T waves can be a sign of coronary ischemia. bundle branch block. Flat T waves may indicate coronary ischemia or hypokalemia. thyrotoxicosis. or exposure to digitalis. by definition. The most commonly used method for correcting the QT interval for rate is the one formulated by Bazett and published in 1920. Why the Test is Performed . Wellens' syndrome. epinephrine. or CNS disorder. and over-corrects at high heart rates and under-corrects at low heart rates. and RR is the interval from the onset of one QRS complex to the onset of the next QRS complex. the T wave should be deflected opposite the terminal deflection of the QRS complex.. and. this formula tends to be inaccurate. However. Tall or "tented" symmetrical T waves may indicate hyperkalemia. This is known as appropriate T wave discordance. U wave An electrocardiogram of an 18-year-old man showing U waves. left ventricular hypertrophy. paced rhythm) is present. QTc may also be found via the following formula: QTc = QT + 1. which can be distinguished from hyperkalemia by the broad base and slight asymmetry. QT interval The QT interval is measured from the beginning of the QRS complex to the end of the T wave. Normal values for the QT interval are between 0. The QT interval varies based on the heart rate. An inverted U wave may represent myocardial ischemia or left ventricular volume overload. When a conduction abnormality (e. and Class 1A and 3 antiarrhythmics. U waves are thought to represent repolarization of the papillary muscles or Purkinje fibers. Bazett's formula is . measured in seconds. but may be present in hypercalcemia. The U wave is not always seen. It is typically small. Prominent U waves are most often seen in hypokalemia. follows the T wave.30 and 0. as well as in congenital long QT syndrome and in the setting of intracranial hemorrhage.75(Ventricular Rate 60). The QT interval represents on an ECG the total time needed for the ventricles to depolarize and repolarize. where QTc is the QT interval corrected for rate.44 seconds.
Your doctor may order this test if you have chest pain or palpitations. An ECG may be included as part of a routine examination in patients over age 40. Normal Results • • Heart rate: 50 to 100 beats per minute Heart rhythm: consistent and even What Abnormal Results Mean Abnormal ECG results may be a sign of • • • • • • • • • • • • • Abnormal heart rhythms (arrhythmias) Cardiac muscle defect Congenital heart defect Coronary artery disease Ectopic heartbeat Enlargement of the heart Faster-than-normal heart rate (tachycardia) Heart valve disease Inflammation of the heart (myocarditis) Changes in the amount of electrolytes (chemicals in the blood) Past heart attack Present or impending heart attack Slower-than-normal heart rate (bradycardia) Additional conditions under which the test may be performed include the following: • • • • • • • Alcoholic cardiomyopathy Anorexia nervosa Aortic dissection Aortic insufficiency Aortic stenosis Atrial fibrillation/flutter Atrial myxoma .An ECG is used to measure: • • • • Any damage to the heart How fast your heart is beating and whether it is beating normally The effects of drugs or devices used to control the heart (such as a pacemaker) The size and position of your heart chambers An ECG is a very useful tool for determining whether a person has heart disease.
acute Mitral regurgitation.• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Atrial septal defect Cardiac tamponade Coarctation of the aorta Complicated alcohol abstinence (delirium tremens) Coronary artery spasm Digitalis toxicity Dilated cardiomyopathy Drug-induced lupus erythematosus Familial periodic paralysis Guillain-Barre Heart failure Hyperkalemia Hypertensive heart disease Hypertrophic cardiomyopathy Hypoparathyroidism Idiopathic cardiomyopathy Infective endocarditis Insomnia Ischemic cardiomyopathy Left-sided heart failure Lyme disease Mitral regurgitation. chronic Mitral stenosis Mitral valve prolapse Multifocal atrial tachycardia Narcolepsy Obstructive sleep apnea Paroxysmal supraventricular tachycardia Patent ductus arteriosus Pericarditis o Bacterial pericarditis o Constrictive pericarditis o Post-MI pericarditis Peripartum cardiomyopathy Primary amyloid Primary hyperaldosteronism Primary hyperparathyroidism Primary pulmonary hypertension Pulmonary embolus Pulmonary valve stenosis Restrictive cardiomyopathy Right-sided heart failure Sick sinus syndrome Stable angina Stroke .
• • • • • • • • • • • Systemic lupus erythematosus Tetralogy of Fallot Thyrotoxic periodic paralysis Transient ischemic attack (TIA) Transposition of the great vessels Tricuspid regurgitation Type 2 diabetes Unstable angina Ventricular septal defect Ventricular tachycardia Wolff-Parkinson-White syndrome .
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