PaavaiInstitutions Department of BME

UNIT-I
CARDIAC EQUIPMENT

Electrocardiograph, Normal and Abnormal Waves, Heart rate monitor, Holter Monitor,
Phonocardiography, ECG machine maintenance and troubleshooting, Cardiac Pacemaker, Internal
and External Pacemaker– Batteries, AC and DC Defibrillator- Internal and External, Defibrillator
Protection Circuit, Cardiac ablation catheter.

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S.NO TERMS TECHNICAL MEANING LITERAL MEANING

A brief period follows the P wave

and represents the time in which the The time when the electrical signal
Isoelectric travels through the AV node and
1 impulse is traveling within the AV
period bundle of His.
node (where conduction slows) and
the bundle of His
P-Rinterval P-R segment: Extends The duration from the start of the P
from the end of the P wave until the wave to the start of the QRS complex,
2 P-R interval
beginning of the QRS complex and indicating the time between atrial and
reflects an isoelectric period ventricular depolarization
3 T wave Represents ventricular depolarization Represents ventricular depolarization
Represents ventricular depolarization Represents ventricular depolarization
4 QRS complex
(contraction). or contraction
This isoelectric period represents a
time period during which the
The isoelectric phase during complete
ventricles are completely depolarized
5 ST segment ventricular depolarization, often
(plateau phase). The ST segment
affected by ischemia or hypoxia
may be depressed or elevated with
ischemia or hypoxia

is a type of polymorphic VT in which the A type of polymorphic ventricular

Torsades de QRS complexes continuously vary and tachycardia with twisting QRS
6
Pointes (TdP) appear to twist, so that the pattern complexes.
resembles ventricular fibrillation

is a type of polymorphic VT in which the Intermittent atrial tachycardia

Paroxysmal QRS complexes continuously vary and occurring between episodes of normal
7
AT appear to twist, so that the pattern sinus rhythm.
resembles ventricular fibrillation

is the physiological phenomenon of

Heart rate variation in the time interval between
8 variability heartbeats. It is measured by the Physiological variation in the time
(HRV): variation in the beat-to-beat interval. between heartbeats

Ventricular Lethal malfunction of the heart

9 is a lethal malfunction of the heart characterized by chaotic, uncoordinated
fibrillation
ventricular contractions

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UNIT I
CARDIAC EQUIPMENT

1.1. ELECTROCARDIOGRAPH
The electrocardiograph (ECG) is an instrument, which records the electrical activity of the heart.
Electrical signals from the heart characteristically precede the normal mechanical function and
monitoring of these signals has great clinical significance. ECG provides valuable information
about a wide range of cardiac disorders such as the presence of an inactive part (infarction) or an
Enlargement (cardiac hypertrophy) of the heart muscle. Electrocardiographs are used in
catheterization laboratories, coronary care units and for routine diagnostic applications in cardiology.
Although the electric field generated by the heart can be best characterized by vector quantities, it is
generally convenient to directly measure only scalar quantities, i.e. a voltage difference of mVorder
between the given points of the body.
 The diagnostically useful frequency range is usually accepted as 0.05 to 150 Hz (Golden et al
1973). The amplifier and writing part should faithfully reproduce signals in this range. A good low
frequency response is essential to ensure stability of the baseline.
 High frequency response is a compromise of several factors like isolation between useful ECG
signal from other signals of biological origin (my graphic potentials) and limitations of the direct
writing pen recorders due to mass, inertia and friction.
 The interference of nonbiologicalorigin can be handled by using modern differential amplifiers,
which are capable ofproviding excellent rejection capabilities. CMRR of the order of 100–120 dB
with 5 kW unbalance in the leads is a desirable feature of ECG machines.
 In addition to this, under specially adverse circumstances, it becomes necessary to include a notch
filter tuned to 50 Hz to reject hum duet power mains. The instability of the baseline, originating from
the changes of the contact impedance, demands the application of the automatic baseline stabilizing
circuit. A minimum of two paper speeds is necessary (25 and 50 mm per sec) for ECG recording.

1.2 Block diagram description of an Electrocardiograph

Figure 1.2 shows the block diagram of an electrocardiograph machine. The potentials picked up
by the patient electrodes are taken to the lead selector switch. In the lead selector, the electrodes are

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Figure 1.2 Block diagram description of an Electrocardiograph

selected two by two according to the lead program. By means of capacitive coupling, the signal is
connected symmetrically to the long-tail pair differential preamplifier. The preamplifier is usually a
three or four stage differential amplifier having a sufficiently large negative current feedback, from
the end stage to the first stage, which gives a stabilizing effect. The amplified output signal is picked
up single-ended and is given to the power amplifier. The power amplifier is generally of the push-
pull differential type.
The base of one input transistor of this amplifier is driven by the pre-amplified unsymmetrical
signal. The base of the other transistor is driven by the feedback signal resulting from the pen
position and connected via frequency selective network. The output of the power amplifier is single-
ended and is fed to the pen motor, which deflects the writing arm on the paper. A direct writing
recorder is usually adequate since the ECG signal of interest has limited bandwidth. Frequency
selective network is an R–C network, which provides necessary damping of the pen motor and is
preset by the manufacturer. The auxiliary circuits provide a 1 mV calibration signal and automatic
blocking of the amplifier during a change in the position of the lead switch. It may include a speed
control circuit for the chart drive motor. A‘stand by’ mode of operation is generally provided on the
electrocardiograph. In this mode. the stylus moves in response to input signals, but the paper is
stationary. This mode allows the operator to adjust the gain and baseline position controls without
wasting paper. Electrocardiograms are almost invariably recorded on graph paper with horizontal

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and vertical lines at 1 mm intervals with a thicker line at 5 mm intervals. Time measurements and
heart rate measurements are made horizontally on the electrocardiogram. For routine work, the paper
recording speed is 25 mm/s. Amplitude measurements are made vertically in millivolts. The
sensitivity of an electrocardiograph is typically set at 10 mm/mV.

1.3 Cardiac conduction:

In the normal heart, electrical impulses originate in the upper right atrium at the senatorial (SA) node
(AKA the cardiac pacemaker). As the impulse leaves
the SA node, it travels through Bachman’s bundle to the left atrium and down the intermodal tracts
to the atrioventricular (AV) node and from there down the Bundle of His to the bundle branches and
ventricles, and to the Purkinje fibers.

Because the muscle of the left ventricle is thicker than that of the right, the impulses travel more
rapidly down the left bundle branch than the right so that the ventricles can contract at the same
time.
A fibrous ring that does not conduct electrical impulses separates the atria from the ventricles, so
impulses must pass through the AV node to reach the ventricles (the reason an AV block may be
life-threatening).
The SA node at rest fires 60 to 100 times in adults per minute and 60 to 190 times per minute in
infants and children (depending on the age and level of activity) while the junction tissue about the
AV node (cardiac backup pacemaker) fires 40 to 60 times per minute in the adult and 50 to 80 times
per minute in children younger than 3. The primary role of the AV node is to delay impulses by

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about 0.04 second so that the ventricles can fill adequately and don’t contract too rapidly.
The Purkinje fibers not only conduct impulses but can also serve as a backup pacemaker, able to
discharge between 20 to 40 times per minute in the adult and 40 to 50 times per minutes in children
under age 3. Pacemaker cells in the junction tissue (about the AV node) and the Purkinje fibers are
usually not triggered unless conduction above is blocked. When impulses are transmitted backward
toward the atria instead of downward from the atria, this is referred to as retrograde conduction.
The ability of cells, such as the SA and AV nodes to spontaneously initiate an impulse is referred to
as automaticity. The degree of cell response (resulting from ion shifts) is the excitability. The ability
of cells to transmit electrical impulses is their conductivity, and the degree of contraction in response
to the electrical impulse is the contractility.

The heart goes through 5 phases of depolarization-repolarization:

1. Period of rapid depolarization (contraction) during which sodium and calcium channels are open
and sodium moves quickly into the cell and calcium more slowly.
2. Early depolarization during which the sodium channels close.
3. Plateau phase in which calcium continues to flow into the cell and potassium flows out. (Note
that phases 1, 2, and the beginning of 3 are referred to as the refractory period because no stimulus
can excite/depolarize the cell).

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4. Rapid depolarization during which calcium channels close but potassium flows out of the cell at
increased speed. (The last half of this phase is the relative refractory period because a strong
stimulus may excite/depolarize the cell.
5. Resting phase during which the sodium-potassium pump allows potassium inside the cell and
sodium outside while the cell becomes impermeable to sodium. Some potassium may flow out of the
cell. The cell prepares for a stimulus. Note: When no electrical activity is taking place, the cells are
considered polarized.

1.3.1 Electrocardiogram and conduction

On the EKG tracing, the baseline is referred to the isoelectric line because there is no voltage during
this time.

 P-wave: represents atrial depolarization (which causes contraction) as the electrical impulse
spreads from the SA node through the atria (usually 0.08 to 0.10 second).

 Isoelectric period: A brief period follows the P wave and represents the time in which the
impulse is traveling within the AV node (where conduction slows) and the bundle of His.
 P-R interval: Extends from the beginning of the P wave until the beginning of the QRS
complex and reflects the time between the onset of atrial depolarization and the onset of ventricular
depolarization. The duration usually ranges from 0.12 to 0.20 second.
 P-R segment: Extends from the end of the P wave until the beginning of the QRS complex
and reflects an isoelectric period.
 QRS complex: Represents ventricular depolarization (contraction). The Q is downward
deflection; R, upward, and S down (in most leads). The duration is usually 0.06 to 0.10 second.
Prolongation of the QRS segment indicates impaired conduction. The shape of the QRS segment on
the EKG tracing may vary from that above depending on the lead used or the presence of abnormal
conduction. Atrial depolarization occurs during this time as well.
 ST segment: This isoelectric period represents a time period during which the ventricles are

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completely depolarized (plateau phase). The ST segment may be depressed or elevated with
ischemia or hypoxia.
 T wave: Represents ventricular repolarization.
1.3.2 Recognizingcardiacabnormalities:

This is a form of supra ventricular tachycardia that has a rate of 150 to

250bpm.Thisrapidrateshortensdiastole(atrialkickislost),socardiacoutputis decreased, resulting in
decreased blood flow to the coronary arteries and my ocardial ischemia.
Iftheatrialtachy cardia hasaregularrateandrhythmthe Pwaveshouldbepresent with every QRS but it
may not be visible because of the speed ofcontractions. In this type of tachycardia, the QRS complex
usually appearsnormal. The T wave is also usually normal but may be inverted if the
heartbecomesischemic,especiallyifthe tachycardia isprolonged.
Variations:
AT with block: The conduction through the AV node becomes impaired with the rapid heartrate as
the AV node begins to block impulses to protect the ventricles. Typically, the heart rate is between
150 and 250. When the block is present, more than one P wave occurs before each QRS; otherwise,
the P wave may be hidden. The block may be constant (resulting in a regular rhythm) or variable
(irregular rhythm). QRS is usually normal but may be prolonged with block.

Multifocal (chaotic) AT: Firing occurs at multiple ectopic atrial sites at rates usually ranging from
100 to 130 bpm (although it may occur at lower rates). The rhythm is typically irregular with
variability in appearance of P waves (each site of atrial origin producing a different-appearing P
wave).
QRS is usually normal, but the P-R interval may vary depending on how close the atrial trigger is to
the AV node. MAT is most often associated with chronic pulmonary disease and hypoxia but may
also occur with CHF, acute MI, mitral stenos is, and electrolyte imbalances (hypocalcaemia, and

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hypomagnesaemia).

Paroxysmal AT: PAT occurs intermittently and occurs between episodes of normal sinus rhythm,
usually at a rate of 150 to 250 while occurring. The rate is regular but the P wave is abnormal and
may be hidden but should be present for each QRS. The P-R interval is the same for all cycles. The
QRS may be normal or abnormal. PAT is often preceded by PACs that trigger the PAT.

Afib is the most common atrial arrhythmia and is associated with atherosclerosis, rheumatic heart
disease, CHF, thyrotoxicos is, MI,cardio myo pathy, alular disease, congenital heart disease,
pulmonarydisease, and post-surgical cardiac procedures. This rapid pattern of disorganized atrial
contractions has a rate of 400 to 700 but the
ventricularratemayvaryfrom110to160becauseofblockoftheextrabeatsattheAVnode.
The rhythm is irregular, P waves absent (so P-R interval cannot beassessed), and QRS usually
normal but may appear abnormal if rate veryrapid.Becausetherapidatrial ratemakestheatriaquiver,
atrialkick islost,resultingindecreasedcardiacoutput.

This is a form of supraventricular tachycardia. The atrial depolarization/contraction rate ranges from
250 to 460 but the most common atrial rate is 300, and the most common ventricular rate is 150 (2:1)
although it may on occasion be as high as 300 (1:1), depending on the amount of block that occurs at
the AV node.

The atrial rhythm is usually regular with a fixed counterclockwise (occasionally clockwise) impulse

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in a reentry circuit. The ventricular rate may be irregular or regular, depending on the amount of
block.

P waves appear as flutter (F) waves in a sawtooth pattern. The F waves may be hidden with rapid
heartrates. The P-R interval may be consistent or varied, and the QRS complex is usually normal
although abnormalities may occur. Atrial flutter is considered a form of supraventricular tachycardia.

Atrial flutter is associated with rheumatic heart disease, atherosclerotic heart disease, CHF,MI,
myocardial ischemia, thyrotoxicosis, and post-cardiac surgery

Awandering atrial pacemaker is characterized by stimuli arising from different supraventricular sites,
some from the SA node, some from other sites in the right atrium, and some from the AV junctional
tissue.

This arrhythmia is often transient and may occur as a normal variant in young patients and athletes.
Not the different shapes of the P wave (depending on the stimulus). The rhythm is irregular but
the heart rate is usually normal or bradycardic. The P-R interval may vary but the QRS complex and
T wave usually appear normal although the Q-T interval may vary. This arrhythmia is usually not
serious but may be caused by rheumatic carditis and digitalis toxicity.

Also known as premature atrial contractions, PACs arise from an atrialstimulus outside of the SA
node that fires before the SA node can fire
again,resultinginaprematurecontraction.PACsoccuroccasionallyinmostpeoplealthough they lead to
more serious arrhythmias in patients with heartdisease and may indicate CHF or imbalance in
electrolytes in patients withan MI. This extra stimulus disrupts the pattern of the SA node, causing it

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tofire earlyafter the PAC.

In some cases, not all of the PACs are conducted through the AV node because they arrive at the
node before the AV node is repolarized. PACs are characterized by an irregular rhythm and heartrate
that may be increased, a P-R interval that is normal or slightly shortened. P waves from the PAC
appear abnormal or may be superimposed on the T wave. The P-R interval is usually normal but may
be prolonged. The QRS complex is also usually normal.PACs that occur every other beat are
referred to as atrial bigeminy; and every third beat, as atrial trigeminy and so on.

Sinus bradycardia with a heartrate of less than 60 is a normal variant in some people, such as
athletes, and may occur during sleep. Some drugs, such as beta blockers, digitalis, and calcium
channel blockers, slow the heartrate and some heart conditions (cardiomyopathy, myocarditis, and
post inferior wall MI) as well. Patients are usually asymptomatic until the rate falls below 45 bpm.

Typically, the EKG shows a normal reading except for the heartrate.

With first degree atrioventricular block, all supraventricular impulses are conducted to the ventricles,
but the conduction is prolonged at the AV node. Characteristics include variable heartrate (usually
between 60 and 90), regular rhythm, normal P waves that precede each QRS, and prolonged P-R
interval (0.20 to 1.0). The QRS complex usually appears normal unless there are other problems,
such as a bundle branch block.

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With second degree AV block (also referred to as Wenckebach block orMobitz type I), the
conduction times from atrial impulses
becomeprogressivelylongeruntilonefailstoconduct,resultinginaPwavewithoutasubsequent
QRSandapause,afterwhichtheprocessrepeats.Characteristics include normal heartrate, irregular
rhythm (although 2:1 rhythm may occur), gradually prolonged P-R interval, and the QRS complex is
usually normal.

This AV block is commonly referred to as Mobitz II and occurs when the failure of an impulse to
conduct to the ventricles is sudden and not a result of progressive conduction times. This type of
block usually results from bilateral bundle branch blocks rather than a block at the AV node.
Characteristics include heartrate variable, irregular rhythm (although blocks may be regular at 2:1),
P waves that are usually normal but an occasional P wave may be missing a QRS complex, P-R
interval is normal for all conducted beats (before and after blocks), and conduction to the ventricles
is slow because of the blocks.

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With third degree AV block, all atrial impulses (usually originating in the SA node) are blocked at

the AV node or bundle branches.Characteristics include a ventricular rate of less than 45 bpm and a
regular rhythm. P waves are normal but disassociated from the QRS complex, the P- R interval is
inconsistent because the P waves and the QRS are not associated, and the QRS complex is normal if
controlled by a junctional pacemaker or wide if controlled by ventricular pacemaker

Junctional rhythms occur when electrical stimulation of the ventricles originates near or within the
AV node (not the SA node). Characteristics include a regular rhythm but heartrate of less than 60
bpm (although some junctional rhythms are accelerated). The P wave is usually not visible but may

be buried in the QRS complex or slightly before or after. The P-R interval is usually abnormally
short, less than 0.12 second if a P wave is visible before the QRS complex. If visible, the P wave
may be inverted in lead II. The QRS complex, Q-T interval, and ST segment are usually normal.

VF occurs when the electrical stimulation of the ventricles is chaotic with stimuli arising from
various foci but insufficient to adequately contract the ventricles, which instead quiver, so there is no
cardiac output. VF may result from MI, myocardial ischemia, electrolyte imbalance, electric shock,

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hypothermia, and acid-base imbalance.

Characteristics include undetermined rate, rhythm, P wave, P-R interval, duration of QRS complex,
or T wave. The EKG shows fibrillatory waves. Note that larger fibrillatory waves (indicating some
electrical activity in the heart) are easier to convert than smaller waves.

VT (often referred to as V-tach) is an unstable rhythm that occurs with ventricular rates greater
than100 and with 3 or more PVCs in a row. This rhythm often indicates the beginning of cardiac
arrest and occurs before ventricular fibrillation.

Characteristics include undetermined atrial rhythm but regular or slightly irregular ventricular
rhythm, ventricular rate of 100 to 250 bpm, P waves are usually absent (so unable to determine atrial
rate) or not related to QRS complexes, and the P-R wave cannot, therefore, usually be measured. The
QRS complex is wide and bizarrely shaped with duration longer than 0.12 second. With
monomorphic VT, the QRS look alike; but with polymorphic VT, they appear multiform. Large T
waves may follow the QRS but in the opposite direction.

Note:Tachycardiasareoftenclassifiedaseitherwidecomplexornarrowcomplex.

Widecomplexhasa QRScomplexgreaterthan
0.12second;andnarrowcomplex,lessthan
0.12 second.Wide complex
tachycardiaoriginatesbelowtheAVnode;butnarrowco
mplexissupraventricular.

With this type of supraventricular tachycardia, three or more

prematurejunctionalcontractionsoccuroneafteranotherwhenstimuliariseintheAVjunctional tissue,
overriding the SA node stimuli and taking over as cardiacpacemaker. Thus, the atria are depolarized
through retrograde conduction(upward insteadofdownward).

The heartrate is usually 100 to 200 bpm; and the rhythm, regular. The P wave is typically inverted in

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leads I, III, and aVF and may precede, follow, or be hidden in the QRS segment. If the P wave
precedes the QRS complex, then the P-R interval is less than 0.12 second. The QRS is usually
normal, and T wave may appear normal or distorted if the P wave occurs within it. If the heartrate is
too rapid, the T wave may be undetectable.

Torsades de Pointes (TdP) is a type of polymorphic VT in which the QRS complexes continuously
vary and appear to twist, so that the patternresembles ventricular fibrillation. This pattern is usually
initiated by prolonged QT/QTU intervals that commonly includes a large U wave that follows the T
wave or merges with it and wide notched, or biphasic T wave or T wave alternans.

The ventricular rate may vary from 150 to 250 bpm. TdP usually occurs in bursts and is not a
sustained rhythm, so it’s important to assess the EKG for QT prolongation (≥0.6 second/600 ms).
TdP may be associated with hypokalemia, hypomagnesemia, and bradycardia.

PVCs, also referred to as premature ventricular contractions, are ectopic beats that occur (singly or
in clusters) and usually cause no problem in healthy patients; however, if the person has preexisting
heart disease, PVCs can indicate high risk for lethal ventricular arrhythmias.

Conduction through the ventricles generally occurs through the muscle cells rather than through the
Purkinje fibers. PVCs occur because of premature depolarization of ventricular cells or Purkinje
system. PVCs may be associated with hypoxia, myocardial ischemia, electrolyte imbalance
(hypokalemia, acidosis), exercise, caffeine, alcohol, and digitalis toxicity.

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Heartrate usually is between 60 and 100 and rhythm irregular when ectopic beats occur. The P wave
usually does not precede a PVC but one may follow the PVC because of retrograde conduction.
There is no P-R interval, but in the rare instance when a P wave precedes a PVC, the P-R interval is
shortened. The QRS complex is wide and bizarrely shaped and duration greater than 0.12 second. T
waves are generally in the opposite direction from the QRS complex.

With RBBB, the depolarisation of the right ventricle is delayed because the block requires that
depolarisation spread from the AV node, down the bundle of His and left bundle branch and across
the septum from the left ventricle. RBBB is associated with anterior wall MI, pulmonary embolism,
and coronary artery disease. RBBB can also occur without preexisting heart disease and, if isolated,
is of little concern.

Characteristics include normal P wave, QRS duration greater than 0.12 second if complete block and
slightly less if incomplete. The prolonged QRS appears in an M shape in V1 to V3 and a W shape in
V6. The S wave is slurred in leads I, aVL, V5, and V6 and deep in V5 and V6. T waves are
inverted in the right precordial leads (V1 to V3) and upright in the left. The P-R interval is within
normal parameters. The heartrate and rhythm are usually normal.

With LBBB, the depolarisation is essentially in reverse of the RBBB because the conduction spreads
first to the right ventricle and then across the septum to the left, resulting in the reverse of the W and
M QRS patterns with the W shape in V1 and the M shape in V6. LBBB is associated with aortic
stenosis, anterior MI, dilated cardiomyopathy, hyperkalemia, digoxin toxicity, and ischemic cardiac
disease.

In a normal heartbeat, the septum is activated from left to right, and this produces small Q waves in

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the lateral leads, but the LBBB eliminates the septal Q waves in the lateral leads (I, V5 and V6), but
small Q waves may be seen in aVL. The QRS duration is extended to greater than 0.12 second. The
R wave peak time is prolonged to greater than 0.06 second in the left precordial leads (V6 and V6),
and the R waves are tall in the lateral leads (I, V5, V6). S waves are deep in the right precordial leads
(V1 and V3)

Asystole occurs when there is no electrical activity in the heart and the patient is in cardiopulmonary
arrest. This is not a shockable condition.

With PEA, the heart muscle is unable to contract even though electrical activity occurs, most often
because of hypovolemia and hypoxemia. The EKG may show a normal sinus rhythm, V-tach,
bradycardia or other rhythms, but the patient is unconscious, cyanotic and no heartrate is detectable.
This is not a shockable condition because the electrical activity of the heart is functioning.

1.4 Measurement of Heart Rate

Heart rate is derived by the amplification of the ECG signal and by measuring either the average
orinstantaneous time intervals between two successive R peaks. Techniques used to calculate
heartrate include:

• Average calculationThis is the oldest and most popular technique. An average rate (beats/min) is
calculated by counting the number of pulses in a given time. The average method ofcalculation does
not show changes in the time between beats and thus does not representthe true picture of the heart’s
response to exercise, stress and environment.

• Beat-to-beat calculationThis is done by measuring the time (T), in seconds, between

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twoconsecutive pulses, and converting this time into beats/min., using the formula beats/min. = 60/T.
This technique accurately represents the true picture of the heart rate.

• Combination of beat-to-beat calculation with averaging This is based on a four or six

beatsaverage. The advantage of this technique over the averaging techniques is its similaritywith the
beat-to-beat monitoring system.

The normal heart rate measuring range is 0–250 beats/min. Limb or chest ECG electrodes are used
as sensors.
1.4.1 Average Heart Rate Meters
The heart rate meters, which are a part of the patient monitoring systems, are usually of the average
reading type. They work on the basis of converting each R wave of the ECG into a pulse of fixed
amplitude and duration and then determining the average current from these pulses. They
incorporate specially designed frequency to a voltage converter circuit to display the average heart
rate in terms of beats per minute.
1.4.2 Instantaneous heart rate monitoring
Instantaneous heart rate facilitates detection of arrhythmias and permits the timely observation
ofincipient cardiac emergencies. Calculation of heart rate from a patient’s ECG is based upon
thereliable detection of the QRScomplex (Thakor, et al 1983). Most of the instruments are, however,
quite sensitive to the muscle noise (artefact) generated by patient movement. This noise oftencauses
a false high rate that may exceed the high rate alarm.
A method to reduce false alarm is byusing a QRS matched filter, as suggested by Hanna
(1980). This filter is a fifteen sample initeimpulse-response filter whose impulse response shape
approximates the shape of a normal QRS complex. The filter, therefore, would have maximum
absolute output when similarly shaped waveforms are input. The output from other parts of the ECG
waveform, like a T wave, will produce reduced output.
The ECG is sampled every 2 ms. Fast transitionand high amplitude components are attenuated by a
slew rate limiter which reduces the amplitudeof pacemaker artefacts and the probability of counting
these artefacts as beats. Two adjacent 2 mssamples are averaged and the result is a train of 4 ms
samples. In order to remove unnecessaryhigh frequency components of the signal, a 30 Hz, infinite-
impulse-response, Butterworth filter isemployed. This produces 8 ms samples in the process. Any dc
offset with the signal is removed bya 1.25 Hz high-pass filter. The clamped and filtered ECG

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waveform is finally passed through aQRSmatched filter. The beat detector recognizes
QRScomplexes in the processed ECG waveformvalue that has occurred since the last heart beat. If
this value exceeds a threshold value, a heartbeat is counted. The beat interval averaged over several
beats is used to calculate the heart rate fordisplay, alarm limit comparison, trending and recorder
annotation. The threshold in thisarrangement gets automatically adjusted depending upon the value
of the QRSwave amplitudeand the interval between the QRScomplexes. Following each beat, an
inhibitory period of 200 msis introduced during which no heart beat is detected. This reduces the
possibility of the T wavefrom getting counted. The inhibitory period is also kept varied as an inverse
function of the highrate limit, with lower high rate limits giving longer inhibitory periods.
Based on the power spectra estimation of the QRScomplex, Thakor et al (1984 b) have suggestedthat
a bandpass filter with a centre frequency of 17 Hz and a Qof five, yields the best signal to noiseratio.
Such a simple filter should be useful in the design of heart rate meters, arrhythmia monitorsand
implantable pacemakers.The subject of reliable detection of R-wave continues to be of great interest
for the researchers.Besides the hardware approach, a number of software based approaches have
been reported inliterature. Since the ultimate aim of detecting the R-wave is to automate the
interpretation of ECGand detect arrhythmias, they are best covered in the succeeding chapter.
1.5 Heart rate variability :
Heart rate variability (HRV) is the physiological phenomenon of variation in the time interval
between heartbeats. It is measured by the variation in the beat-to-beat interval.
Methods used to detect beats include: ECG, blood pressure, ballistocardiograms,and the pulse wave
signal derived from a photoplethysmograph (PPG). ECG is considered superior because it provides a
clear waveform, which makes it easier to exclude heartbeats not originating in the sinoatrial node.
The term "NN" is used in place of RR to emphasize the fact that the processed beats are "normal"
beats.

There are two primary fluctuations:

 Respiratory arrhythmia (or respiratory
sinus arrhythmia). This heart rate variation is associated
with respiration and faithfully tracks the respiratory
rate across a range of frequencies.

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 Low-frequency oscillations. This heart rate variation is associated with Mayer waves (Traube–Hering–
Mayer waves) of blood pressure and is usually at a frequency of 0.1 Hz, or a 10-second period.

Holter monitor
In medicine Holter monitor is a type of ambulatory electrocardiography device, a portable device
for cardiac monitoring (the monitoring of the electrical activity of the cardiovascular system) for at
least 24 to 72 hours (often for two weeks at a time).
The Holter's most common use is for monitoring ECG heart activity (electrocardiography or ECG).
Its extended recording period is sometimes useful for observing occasional
cardiac arrhythmias which would be difficult to identify in a shorter period. For patients having more
transient symptoms, a cardiac event monitor which can be worn for a month or more can be used.
The Holter monitor was released for commercial production in 1962.When used to study the heart,
much like standard electrocardiography, the Holter monitor records electrical signals from the heart
via a series of electrodes attached to the chest. Electrodes are placed over bones to minimize artifacts
from muscular activity.
The number and position of electrodes varies by model, but most Holter monitors employ between
three and eight. These electrodes are connected to a small piece of equipment that is attached to the
patient's belt or hung around the neck, keeping a log of the heart's electrical activity throughout the
recording period.
A 12-lead Holter system is also available when precise ECG’s information is required to analyse the
exact origin of the abnormal signals

Components
Each Holter system consists of two basic parts – the hardware (called monitor or recorder) for recording the
signal, and software for review and analysis of the record. Advanced Holter recorders are able to display the
signal, which is very useful for checking the signal quality. Very often there is also a “patient button” located
on the front side allowing the patient to press it in specific cases such as sickness, going to bed, taking pills,
etc...
A special mark will be then placed into the record so that the doctors or technicians can quickly pinpoint these
areas when analyzing the signal.

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1.6.1 Recorder
 The size of the recorder differs depending on the manufacturer of the device. The average
dimensions of today's Holter monitors are about 110x70x30 mm but some are only 61x46x20 mm
and weigh 99 g. Most of the devices operate with two AA batteries. In case the batteries are
depleted, some Holters allow their replacement even during monitoring.
 Most of the Holters monitor the ECG via only two or three channels (Note: depending on
manufacturer, different counts of leads and lead systems are used). Today's trend is to minimize the
number of leads to ensure the patient's comfort during recording.
 Although two/three channel recording has been used for a long time in the Holter monitoring
history, as mentioned above, 12 channel Holters have recently appeared. These systems use the
classic Mason-Likar lead system, i.e. producing a signal in the same format as during the common
rest ECG and/or stress test measurement.
 These Holters can occasionally provide information similar to that of an ECG stress test
examination. They are also suitable when analyzing patients after myocardial infarction. Recordings
from these 12-lead monitors are of a significantly lower resolution than those from a standard 12-
lead ECG and in some cases have been shown to provide misleading ST segment representation,
even though some devices allow setting the sampling frequency up to 1000 Hz for special-purpose
exams such as detection of "late potential".
 Another innovation is the inclusion of a triaxial movement sensor, which records the patient's
physical activity, and on examination and software processing, extracts three movement statuses:
sleeping, standing up, or walking.
 Some modern devices also have the ability to record a vocal patient diary entry that can be
later listened to by the doctor. These data help the cardiologist to better identify events in relation to
the patient's activity and diary.

1.6.2 Analyzing software

When the recording of ECG signal is finished (usually after 24 hours), it is up to the physician to
perform the signal analysis. Since it would be extremely time demanding to browse through such a
long signal, there is an integrated automatic analysis process in the software of each Holter device
which automatically determines different sorts of heart beats, rhythms, etc.

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However the success of the automatic analysis is very closely associated with the signal quality. The
quality itself mainly depends on the attachment of the electrodes to the patient body. If these are not
properly attached, electromagnetic disturbance can influence the ECG signal resulting in a very
noisy record.
If the patient moves rapidly, the distortion will be even bigger. Such record is then very difficult to
process. Besides the attachment and quality of electrodes, there are other factors affecting the signal
quality, such as muscle tremors, sampling rate and resolution of the digitized signal (high quality
devices offer higher sampling frequency).
The automatic analysis commonly provides the physician with information about heart beat
morphology, beat interval measurement, heart rate variability, rhythm overview and patient diary
(moments when the patient pressed the patient button). Advanced systems also perform spectral
analysis, ischemic burden evaluation, graph of patient's activity or PQ segment analysis. Another
requirement is the ability of pacemaker impulses detection and analysis. Such ability may be useful
when the physician desires to check for correct basic pacemaker function.

1.7 Cardiac Pacemaker

A cardiac pacemaker (or artificial pacemaker, so as not to be confused with the natural pacemaker of
the heart), is a medical device that generates electrical impulses delivered by electrodes to cause the
heart muscle chambers (the upper, or atria and/or the lower, or ventricles) to contract and therefore
pump blood; by doing so this device replaces and/or regulates the function of the electrical
conduction system of the heart.
The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's
natural pacemaker is not fast enough, or because there is a block in the heart's electrical conduction
system. Modern pacemakers are externally programmable and allow a cardiologist, particularly
a cardiac electrophysiologist to select the optimal pacing modes for individual patients. Modern
devices are demand pacemakers, in which the stimulation of the heart is based on the dynamic
demand of the circulatory system.
A specific type of pacemaker called a defibrillator combines pacemaker and defibrillator functions in
a single implantable device, which should be called a defibrillator, for clarity. Others,
called biventricular pacemakers have multiple electrodes stimulating differing positions within the
lower heart chambers to improve synchronization of the ventricles, the lower chambers of the heart.

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1.7.1 Methods of pacing

1.7.1.1 Percussive pacing
Percussive pacing, also known as transthoracic mechanical pacing, is the use of the closed fist,
usually on the left lower edge of the sternum over the right ventricle in the vena cava, striking from a
distance of 20 – 30 cm to induce a ventricular beat (the British Journal of Anaesthesia suggests this
must be done to raise the ventricular pressure to 10–15 mmHg to induce electrical activity). This is
an old procedure used only as a life-saving means until an electrical pacemaker is brought to the
patient.
1.7.1.2 Transcutaneous pacing
Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial
stabilization of hemodynamically significant bradycardias of all types.
The procedure is performed by placing two pacing pads on the patient's chest, either in the
anterior/lateral position or the anterior/posterior position.
The rescuer selects the pacing rate, and gradually increases the pacing current (measured in mA)
until electrical capture (characterized by a wide QRS complex with a tall, broad T wave on the ECG)
is achieved, with a corresponding pulse. Pacing artifact on the ECG and severe muscle twitching
may make this determination difficult.
External pacing should not be relied upon for an extended period of time. It is an emergency
procedure that acts as a bridge until transvenous pacing or other therapies can be applied.

1.8 PACEMAKER BATTERIES

Energy requirements
•Heart can be stimulated with electric shock
•Min Energy required – 10μJ
•Typically a pulse of 5V, 10mA, 2ms is used
•More than 400μJ causes ventricular fibrillation

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POWER SUPPLY
•Lithium iodide cell used as energy source
•Open-circuit voltage of 2.8V
•Lithium iodide cell provides a long-term battery life
•Limitation – high source resistance

1.9 Plethysmography
 A plethysmograph is an instrument for measuring changes in volume within an organ or
whole body using light.
 (usually resulting from fluctuations in the amount of blood or air it contains)
 A pulse oximeter measures oxygen saturation level (SpO2) and is also a PPG.
 Essentially, a pulse oximeter uses PPG to determine the SpO2 of the local tissue.
Principle
 On a finger or an ear lobe, the PPG normally corresponds to blood vessels under the skin.
 As the vessel expands, more of the light shining through is absorbed, which means that less
light is transmitted through or reflected back.
 Use light emitting diodes (LED)to transmit the light, and a photodiode measures the light
intensity after the light has been reflected or has passed through the body.
 The PPG is the measurement from the photodiode, and it usually has a sawtooth-like pattern.

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1.9.1 DEFIBRILLATOR
 Ventricular fibrillation is a lethal malfunction of the heart
 Effective way to prevent these deathsapply a strong electric shock to the heart with in the first
few minutes after theonset fibrillation
 Devices that deliver such shocks are called defibrillators
 Works by charging a capacitor to a high voltage and then discharging it through the patient’s
body.

Indications
Defibrillation is often an important step in cardiopulmonary resuscitation (CPR). CPR is an
algorithm-based intervention aimed to restore cardiac and pulmonary function. Defibrillation is
indicated only in certain types of cardiac dysrhythmias, specifically ventricular fibrillation (VF)
and pulseless ventricular tachycardia. If the heart has completely stopped, as in asystole or pulseless
electrical activity (PEA), defibrillation is not indicated. Defibrillation is also not indicated if the
patient is conscious or has a pulse. Improperly given electrical shocks can cause dangerous
dysrhythmias, such as ventricular fibrillation.

Application method

The defibrillation device that is usually available out of the medical centres is the automated external
defibrillator (AED), a portable machine that can be used even by users with no previous training.
That is possible because the machine produces pre-recorded voice instructions that guide to the user,
and automatically checks the victim's condition and applies the correct electric shocks. Anyway,
there also exist written instructions of defibrillators that explain the procedure step-by-step.

Outcomes

Survival rates for out-of-hospital cardiac arrests are poor, often less than 10%.Outcome for in-
hospital cardiac arrests are higher at 20%. Within the group of people presenting with cardiac arrest,
the specific cardiac rhythm can significantly impact survival rates. Compared to people presenting
with a non-shockable rhythm (such as asystole or PEA), people with a shockable rhythm (such as
VF or pulseless ventricular tachycardia) have improved survival rates, ranging between 21 and 50%.

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1.9.2 TYPES
Manual models
Manual external defibrillators require the expertise of a healthcare professional.They are used in
conjunction with an electrocardiogram, which can be separate or built-in. A healthcare provider first
diagnoses the cardiac rhythm and then manually determine the voltage and timing for the electrical
shock. These units are primarily found in hospitals and on some ambulances. For instance,
every NHS ambulance in the United Kingdom is equipped with a manual defibrillator for use by the
attending paramedics and technicians. In the United States, many advanced EMTs and
all paramedics are trained to recognize lethal arrhythmias and deliver appropriate electrical therapy
with a manual defibrillator when appropriate.
An internal defibrillator is often used to defibrillate the heart during or after cardiac surgery such as
a heart bypass. The electrodes consist of round metal plates that come in direct contact with the
myocardium. Manual internal defibrillators deliver the shock through paddles placed directly on the
heart.They are mostly used in the operating room and, in rare circumstances, in the emergency room
during an open heart procedure.
Automated external defibrillators
Automated external defibrillators (AEDs) are designed for use by untrained or briefly trained
laypersons. AEDs contain technology for analysis of heart rhythms. As a result, it does not require a
trained health provider to determine whether or not a rhythm is shockable. By making these units
publicly available, AEDs have improved outcomes for sudden out-of-hospital cardiac arrests.
Trained health professionals have more limited use for AEDs than manual external
defibrillators. Recent studies show that AEDs does not improve outcome in patients with in-hospital
cardiac arrests. AEDs have set voltages and does not allow the operator to vary voltage according to
need. AEDs may also delay delivery of effective CPR. For diagnosis of rhythm, AEDs often require
the stopping of chest compressions and rescue breathing. For these reasons, certain bodies, such as
the European Resuscitation Council, recommend using manual external defibrillators over AEDs if
manual external defibrillators are readily available.
As early defibrillation can significantly improve VF outcomes, AEDs have become publicly
available in many easily accessible areas. AEDs have been incorporated into the algorithm for basic
life support (BLS). Many first responders, such as firefighters, policemen, and security guards, are
equipped with them.

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AEDs can be fully automatic or semi-automatic. A semi-automatic AED automatically diagnoses

heart rhythms and determines if a shock is necessary. If a shock is advised, the user must then push a
button to administer the shock. A fully automated AED automatically diagnoses the heart rhythm
and advises the user to stand back while the shock is automatically given. Some types of AEDs come
with advanced features, such as a manual override or an ECG display.
Cardioverter-defibrillators
Implantable cardioverter-defibrillators, also known as automatic internal cardiac defibrillator
(AICD), are implants similar to pacemakers (and many can also perform the pacemaking function).
They constantly monitor the patient's heart rhythm, and automatically administer shocks for various
life-threatening arrhythmias, according to the device's programming. Many modern devices can
distinguish between ventricular fibrillation, ventricular tachycardia, and more benign arrhythmias
like supraventricular tachycardia and atrial fibrillation. Some devices may attempt overdrive pacing
prior to synchronised cardioversion. When the life-threatening arrhythmia is ventricular fibrillation,
the device is programmed to proceed immediately to an unsynchronized shock.
There are cases where the patient's ICD may fire constantly or inappropriately. This is considered
a medical emergency, as it depletes the device's battery life, causes significant discomfort and
anxiety to the patient, and in some cases may actually trigger life-threatening arrhythmias.
Some emergency medical services personnel are now equipped with a ring magnet to place over the
device, which effectively disables the shock function of the device while still allowing the
pacemaker to function (if the device is so equipped). If the device is shocking frequently, but
appropriately, EMS personnel may administer sedation.
A wearable cardioverter defibrillator is a portable external defibrillator that can be worn by at-risk
patients. The unit monitors the patient 24 hours a day and can automatically deliver a biphasic shock
if VF or VT is detected. This device is mainly indicated in patients who are not immediate
candidates for ICDs.

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Important questions
Two marks
1. What purpose pacemaker is used?
2. List the method of stimulating heart muscles?
3. Point the modes of operations pacemaker?
4. Difference between External pacemaker and Internal pacemaker.
5. What are the batteries used for implantable pacemaker?
6. Name the various electrodes used for defibrillator.
7. What is Counter Shock?
8. What is defibrillation? Explain it's types.
9. How abnormal ECG treated?
10. Write the function of Defibrillator.
11. For what purpose DC defibrillator has better than AC Defibrillator?
12. Why did doctor ordered ECG?
13. Can a Heart rate monitor can detect the heart problem?
14. Why is an ECG preferred?
15. What is Supra ventricular tachycardia? Explain it's conditions.
16. What are the most common cause of atrial fibrillation?
17. Define Holter monitor.
18. Why doctor prefer pacemaker to patient?
19. Write short note on Dangerous arrhythmia.
20. Write the precaution While using defibrillator.
16 MARKS
1.Explain detailed about Cardiac Pacemakers.
2.Explain the working principle of capacitive discharge types of cardiac Defibrillator.
3. a) Difference between Internal and external pacemaker
b) Illustrate the concept of internal and external defibrillator.
4. Explain a details about Holter Monitoring?
5. a) Illustrate the concept the AC and DC Defibrillator.
b) What is the safety precautions when using an AED that must be observed?

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6.What is an abnormal rhythm of ECG? Explain it types, Causes, Diagnosis and treatment.
7.Explain detail Heart rate monitor and it's types.
8.Illustrate the concept of ECG, Procedure, Purpose and Application of ECG

REFERENCES

1. L.A Geddes and L.E.Baker, “Principles of Applied Biomedical Instrumentation”, 3rd Edition,
2008.
2. John G. Webster, “Medical Instrumentation Application and Design”, 4th edition, Wiley India
PvtLtd,New Delhi, 2015

NPTEL LINK
https://onlinecourses.nptel.ac.in/noc22_md01/announcements?force=true

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