Electrocardiogram Introduction The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical activity

of the heart in exquisite detail. Interpretation of these details

allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening. The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG. The ECG has evolved over the years.     The standard 12-lead ECG that is used throughout the world was introduced in 1942. It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points of view. This is necessary because no single point (or even 2 or 3 points of view) provides a complete picture of what is going on. To fully understand how an ECG reveals useful information about the condition of your heart requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the function) of the heart.

Basic Anatomy of the Heart The heart is a 4-chambered muscle whose function is to pump blood throughout the body.

The heart is really 2 "half hearts," the right heart and the left heart, which beat simultaneously.

Each of these 2 sides has 2 chambers: a smaller upper chamber called the atrium(together, the 2 are called atria), and a larger lower chamber called the ventricle.

Thus, the 4 chambers of the heart are called the right atrium, right ventricle, left atrium, and left ventricle. This sequence also represents the direction of blood flow through the heart.

The right atrium receives blood that has completed a tour around the body and is depleted of oxygen and other nutrients. This blood returns via 2 large veins: the superior vena cava returning blood from the head, neck, arms, and upper portions of the chest, and the inferior vena cava returning blood from the remainder of the body.

The right atrium pumps this blood into the right ventricle, which, a fraction of a second later, pumps the blood into the blood vessels of the lungs.

The lungs serve 2 functions: to oxygenate the blood by exposing it to the air you breathe in (which is 20% oxygen), and to eliminate the carbon dioxidethat has accumulated in the blood as a result of the body's many metabolicfunctions.

Having passed through the lungs, the blood enters the left atrium, which pumps it into the left ventricle.

The left ventricle then pumps the blood back into the circulatory system of blood vessels (arteries and veins). The blood leaves the left ventricle via the aorta, the largest artery in the body. Because the left ventricle has to exert enough pressure to keep the blood moving throughout all the blood vessels of the body, it is a powerful pump. It is the pressure generated by the left ventricle that gets measured when you have your blood pressure checked. The heart, like all tissues in the body, requires oxygen to function. Indeed, it is the only muscle in the body that never rests. Thus, the heart has reserved for itself its own blood supply.

This blood flows to the heart muscle through a group of arteries that begins less than one-half inch from where the aorta begins. These are known as thecoronary arteries. These arteries deliver oxygen to both the heart muscle and the nerves of the heart.

When something happens so that the flow of blood through a coronary artery gets interrupted, then the part of the heart muscle supplied by that artery begins to die. This is called coronary heart disease, or coronary artery disease. If this condition is not stopped, the heart itself starts to lose its strength to pump blood, a condition known as heart failure.

Nerves of the heart: The heart's function is so important to the body that it has its own electrical system to keep it running independently of the rest of the body's nervous system. When the interruption of coronary blood flow lasts only a few minutes.  The ECG records this electrical activity and depicts it as a series of graph-like tracings. Electrical impulses course through these nerves to trigger the chambers to contract with perfectly synchronized timing much like the distributor and spark plugs of a car make sure that an engine's pistons fire in the right sequence. with many normal variations. and (2) an electrical impulse travels through the atria to reach another area of the heart called theatrioventricular (AV) node. the heart often beats normally.   Even in cases of severe brain damage. An extensive network of nerves runs throughout all 4 chambers of the heart. This is referred to as a heart attack (myocardial infarction). and there is no permanent damage to the heart. athletes at rest have slower heart rates than most people. . which lies in the wall between the 2 ventricles." meaning it discharges all by itself without control from the brain. This rate is set by a small collection of specialized heart cells called the sinoatrial (SA) or sinus node. that part of the heart muscle dies. let's take a look at the heart's electrical system. Before describing the ECG itself. or waves. For example. the sinus node is the heart's "natural pacemaker. the symptoms are called angina. The shapes and frequencies of these tracings reveal abnormalities in the heart's anatomy or function. When the interruption lasts longer. Heart Function and the ECG The heart normally beats between 60 and 100 times per minute. Two events occur with each discharge: (1) both atria contract. Located in the right atrium."   It has "automaticity.

From the AV node.  The normal delay between the contraction of the atria and of the ventricles is 0. Q. these waves can show a wide range of abnormalities of both the electrical conduction system and the muscle tissue of the heart's 4 pumping chambers. Intervals shorter or longer than this range indicate possible problems. When viewed from multiple anatomic-electric perspectives (that is. This reflects the electrical activity produced when the ventricles are recharging for the next contraction (repolarizing). causing them to contract and pump blood.  The third and last common wave in an ECG is the T wave. R. . the letters P. known as the QRS complex. QRS. What You Can Expect During an ECG Few procedures in medicine are easier than an ECG.   Atrial contractions (both right and left) show up as the P wave.  The AV node serves as a relay point to further propagate the electrical impulse. This delay is perfectly timed to account for the physical passage of the blood from the atrium to the ventricle.20 seconds.  Interestingly. and T are not abbreviations for any actual words but were chosen many years ago for their position in the middle of the alphabet.  The electrical activity results in P. Ventricular contractions (both right and left) show as a series of 3 waves. leads).12 to 0. and T waves that have a myriad of sizes and shapes.  You will lie down quietly on a bed or stretcher. The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles contract. an electrical wave travels to both ventricles. Q-R-S. S.

or weakness. In addition to the 12-lead ECG.  These may be changes that are hard to interpret or are not even detected in the handful of heartbeats recorded in the standard 12-lead ECG.  The interpretation of the waves produced by each of these 12 views provides valuable information about the functioning of your heart. an additional "rhythm strip" may be taken. aVL. .  The other points of view represent combinations of the pads placed on the arms and legs. Insulated wires will connect each of these 10 pads to the ECG machine. or other medical professional) will place 6 small adhesive electrode pads across your chest from your lower breast bone (sternum) to an area below your left armpit. and V6 (pronounced Vee One. palpitations. These are called V1. is recorded and analyzed from each of 12 points of view. and so on). V5. Other pads will be placed on each of your arms and legs. Some people with heart rhythm disorders (arrhythmias) or coronary heart disease have symptoms that come and go. V2. the ECG records a few heartbeats on a single sheet of graph paper. V4. aVR.  These symptoms may include brief chest pain or angina. Each heartbeat produces a set of P-QRS-T waves. and aVF.dizziness. Vee Two. II. In some circumstances. medical illnesses elsewhere in the body or various drugs (especially in overdose situations) affect an otherwise healthy heart in ways revealed by diagnostic or suggestive changes in to the ECG changes. called "leads.   This set of waves.  This is especially useful when the heart is beating slower or faster than normal. III . V3." are attached. Six of these points of view are the locations of the 6 pads placed across your chest.  Once these wires. in turn. doctor. A technician (or sometimes a nurse. These are called I. This represents only one point of view but is a good way to see important changes that may be occurring over longer periods of time.

even if they last only a few minutes or seconds. your health care provider will probably recommendambulatory ECG. an ECG will generally be done. An alternative method is to record the heartbeats only intermittently but for a longer period of time. Reasons to Have an ECG Heart problems can produce a wide array of symptoms. Common symptoms that frequently require an ECG include the following:     Chest pain or discomfort Shortness of breath Nausea Weakness . days or weeks.  For this test.  This is a good way to "catch" and document any temporary or intermittent abnormalities such as irregular heartbeats. injury.  Without the benefit of an ECG. If this happens to you. and it is frustrating because your health care provider cannot properly diagnose or treat your problem until it has been documented on ECG.  This is a common occurrence. it may be impossible to tell whether these symptoms are being caused by a heart problem or just mimicking one. or condition known to not affect the heart. if necessary).  Therefore.  Long-term monitoring significantly increases your chances of "catching" any abnormalities on the ECG. If you are not having symptoms when you see your health care provider. unless your symptoms are explained by an illness. you are attached to an ECG recording device (sometimes called a Holter monitor) that records every heartbeat for periods of 24 hours (or longer. your ECG result may be perfectly normal.

never exercises. Examples are overdoses of certain drugs (such as certain antidepressants. train conductors. Common Causes of ECG Tracings If you are having symptoms. Your ECG may be completely normal despite the presence of significant heart disease. If you are about to have surgery with general anesthesia. This first ECG serves as a screening tool to detect any cardiac problems and as a baseline for comparison of future ECGs.    Palpitations (rapid or pounding heartbeats or increased awareness of heart beating) Anxiety Abdominal pain Fainting (syncope) ECG often reveals a problem that is not primarily cardiac in nature. and bus drivers) require ECGs as well. Anyone aged 40 years or older should have an ECG done. called Guidelines for ECG. People of any age who are in occupations that stress the heart (professional athletes or firefighters. is published by the Joint Committee of the AHA/ACC (American Heart Association/American College of Cardiology). you will have an ECG to detect any latent (silent) cardiac conditions that might worsen with the stresses of surgery and anesthesia. cocaine. or amphetamines) or electrolyte abnormalities (especially potassium). and eats a fatty diet has his coronary arteries 70% blocked bycholesterol deposits. Here's an example: An overweight man who smokes. A complete list of who should obtain an ECG. the ECG is just one test your health care provider will use in making an overall evaluation. . for example) or involve public safety (commercial airline pilots.

This may manifest as fatigue. shortness of breath. the telltale ECG changes will be temporary as well. during the quiet resting conditions under which most ECGs are performed. and. such as bleeding. or performs similar activity). and the ECG changes will be permanent. it is especially important to go to a hospital emergency department in the early stages of a heart attack. the heart muscle likely will not get the blood flow it needs. In these circumstances. the ECG usually identifies the problem before a full-blown heart attack has occurred. on the other hand. like a burnedout light bulb. however. digs a hole for a fence. affected portion(s) of the heart will be electrically silent. therefore.  An unsuspecting person may attribute these symptoms to overexertion and will slow down or stop the exercise and never realize that is heart is producing warning signs. Other people are not eligible to receive this medication because of potential complications. or discomfort in the chest or arms. chops wood. coronary blood flow will be sufficient to give the heart muscle the oxygen it needs. For these reasons.  Some people are eligible to receive a medication that rapidly dissolves the coronary artery blockage. On a treadmill under continuous ECG monitoring. When a heart attack has occurred. a part of the actual heart muscle has died. no longer radiate energy. his heart will need to pump twice as much blood to deliver twice as much oxygen to the muscles of the arms and legs.  This shows up as changes in the voltages of the ECG. With 70% blockage of the coronary arteries. may be perfectly normal. Despite this. a normal ECG would give a false sense of security that all is well with the heart. when the blockage is temporary.  If this person exercises on a treadmill (or shovels snow.  In a heart attack. it is hoped. The ECG. In cases of angina. especially of the QRS complex. .   This medication works only if it is given within 6 hours after the onset of symptoms.

 Depending on the condition of the rest of the heart (the coronary arteries and the valves.  Sometimes a body's natural pacemaker malfunctions despite an otherwise perfectly healthy heart. if the coronary artery supplying the sinus node is blocked. If the failure is partial. He died in December 2001. the AV node will fire on its own. These cells are subject to malfunction when starved of oxygen by blockage of a coronary artery. When this occurs. . and no signal to trigger the AV node. no atrial contraction. This is called cardiac arrest and usually causes death.Electrical problems within the heart may disrupt the heart's natural pacemaker. aged 86 years.) This was the situation for Arne Larsson. Fortunately. The heart will stop pumping. the heart may beat too fast. the heart rate will slow down.  The extensive electrical network of nerves and nerve centers that coordinate the firing of the 4 chambers is made of living cells that require oxygen every bit as much as the heart muscle. Sometimes the heart's 2 ventricles beat so rapidly that very little or no blood at all is pumped because there is not enough time between contractions for the ventricles to fill. This condition. known as sick sinus syndrome. this slower rate may or may not result in symptoms. the AV node has automaticity of its own. (This is the equivalent to a car engine that doesn't run well because of a spark plug problem.  Because a heart so affected loses its ability to speed up when needed. too slowly. it is generally only a matter of time before the condition results in noticeable symptoms.  For example. of causes unrelated to his heart. a Swedish engineer who received the first artificial pacemaker in 1958. but at the slower rate of 35-60 times per minute. the sinus node may fail. or too irregularly to sustain its normal pumping function. for example). then there will be no activation of the atria. If the failure is complete. is one of the more common reasons that people need an artificial pacemaker. This means that in the absence of a normal incoming signal from the sinus node.

. shopping malls.  This can make it difficult to identify which problems require urgent treatment. thus giving the heart's pacemaker a chance to kick in at a normal rate. and airplanes Interpreting the ECG Results Interpretation of an ECG is no simple matter. known as defibrillation.  Some people are even born with ECG abnormalities. Because the brain and heart cannot survive total loss of blood flow lasting much more than about 10 minutes.  This issue becomes crucial in an emergency situation when a person has symptoms consistent with a heart problem and an abnormal ECG. a well-placed electrical shock across the chest may be life saving. Some or all of the abnormalities may have been caused by an event long in the past and unrelated to the current situation.  There are hundreds of patterns to recognize. A device called an AED (automatic external defibrillator) is increasingly being made available in public locations such as large office buildings. neutralizes all the abnormal electric circuits.   When this occurs. This dangerous condition is known as ventricular tachycardia if the heartbeat is regular and ventricular fibrillation if the heartbeat is irregular.  It may be impossible to tell how long an abnormality has been present. The shock. it is crucial that the shock be delivered within this time frame. golf courses.

 A copy of your ECG can be shrunk to credit card size and laminated to be carried in your wallet. ask your health care provider about doing this for you. If you have an abnormal ECG or you travel a lot. purse. This is the equivalent of examining a car that has been in both a recent car accident and accidents in the past. Which dents were caused by which accident? For these reasons. AV . you would be wise to keep a recent copy of your ECG handy in your wallet. or car glove compartment for immediate availability. Media file 1: Rhythm strip showing a normal 12-lead ECG. Media type: Rhythm Strip Media file 2: Conducting system of the heart: SA means sinoatrial node.  This way you will be able to provide your baseline ECG to a very grateful emergency care provider in case you unexpectedly end up in an emergency department. especially in the middle of the night or far from home. if you have either a heart condition or an abnormal ECG.

respectively. Media type: Photo Media file 4: Location for placement of the 6 precordial leads across the chest around the heart (V1 to V6). and are the nerves that spread the electric impulse from the AV node into the ventricles.0 millivolts. Media type: Illustration . RB and LB mean right and left bundle. Media type: Illustration Media file 3: Basic P-QRS-T wave sequence: Strip shows a simple sequence where M equals 1.meansatrioventricular node.

FACC.Media file 5: A cross-section of the heart: The 6 precordial leads showing that P-QRS-T wave shapes vary with position around the heart. Media type: Illustration Media file 6: Rhythm strip of a person who was cardioverted out of ventriculartachycardia by an electric shock. Media type: Rhythm Strip Media file 7: A 12-lead electrocardiogram (ECG) of a person with chest pain. MPH. Image courtesy of Vibhuti N Singh. . MD. It shows heart attack (acute inferior wall myocardial infarction).

. AV node. circulatory system. 12-lead ECG. left atrium. ventricle. fainting. blood pressure. ECG Electrodes Skin Preparation: Clean with an alcohol wipe if necessary. syncope. SA node. QRS interval. oxygen. electrical activity of the heart. heart rhythm disorders. ECG standard leads There are three of these leads. heart failure. sinus node. II and III. sinoatrial node. chest pain. EKG. nausea. ventricular contractions. right atrium. myocardial infarction. heart attack. electrocardiogram results ECG BASICS The electrocardiogram (ECG) is a diagnostic tool that measures and records the electrical activity of the heart in detail. right ventricle. If the patients are very hairy – shave the electrode areas. coronary heart disease. arrhythmias. I. anatomy of the heart. atrioventricular node. blood vessels. anxiety. AED. T wave. heart tracing.Synonyms and Keywords electrocardiogram. atrial contractions. MI. rhythm strip. Being able to interpretate these details allows diagnosis of a wide range of heart problems. angina. heart function. heart. ECG. the left arm being positive. left ventricle. ECG results. lungs. atrium. automatic external defibrillator. palpitations. abnormal ECG tracings. QRS complex. Lead I: is between the right arm and left arm electrodes. QRS wave. P wave.

When viewed from different leads. This is the electrical activity produced when the ventricles are recharging for the next contraction (repolarizing).  Interestingly. line. the left leg again being positive. (Directly under the midpoint of the armpit) ECG Leads . R. sternum. V4.  The electrical activity results in P.Views of the Heart Chest Leads V1 & V2 V3 & V4 V5 & V6 View Right Ventricle Septum/Lateral Left Ventricle Anterior/Lateral Left Ventricle The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles contract. the left leg being positive. The third and last common wave in an ECG is the T wave. line. Q. . and T are not abbreviations for any actual words but were chosen many years ago for their position in the middle of the alphabet. the letters P. Ventricular contractions show as a series known as the QRS complex. and T waves that are of different sizes and shapes. Directly Fifth Level between intercostal midclavicular anterior axillary with V4 V6: Level with V5 at left midaxillary line. QRS. Chest V1: V2: V3: V4: V5: Fourth Fourth intercostal intercostal Electrode space space to to the the leads space at left at right Left V2 of of the the and Placement sternum.    Atrial contractions show up as the P wave. Lead III: is between the left arm and left leg electrodes. these waves can show a wide range of abnormalities of both the electrical conduction system and the muscle tissue of the hearts 4 pumping chambers.Lead II: is between the right arm and left leg electrodes. S.

and is marked at 1 second intervals on the top and bottom. and represents 0. segment. P-Wave: represents atrial depolarization . segment.ECG Interpretation The graph paper that the ECG records on is standardised to run at 25mm/second. Each small block (defined by lighter lines) on the horizontal axis represents 0. Duration of a waveform. The horizontal axis correlates the length of each electrical event with its duration in time. or interval is determined by counting the blocks from the beginning to the end of the wave.04 seconds.20 seconds.5 mm in height Duration: 0.06 to 0.  Location: Precedes QRS complex Amplitude: Should not exceed 2 to 2.11 seconds .the time necessary for an electrical impulse from the sinoatrial (SA) node to spread throughout the atrial musculature. Five small blocks (shown by heavy lines) is a large block. or interval.

The S wave. It may or may not always be present. the negative deflection.20 seconds. The QRS complex consists of 3 waves: the Q wave.10 seconds .P-R Interval: represents the time it takes an impulse to travel from the atria through the AV node. the R wave.12 to 0. and bundle branches to the Purkinje fibres. The R wave is always the first positive deflection. and the S wave. QRS Complex: represents ventricular depolarisation.  The Q wave is always located at the beginning of the QRS complex.  Location: Extends from the beginning of the P wave to the beginning of the QRS complex Duration: 0. follows the R wave  Location: Amplitude: Follows Normal values the vary with P-R age and interval sex Duration: No longer than 0. bundle of His.

10mm or less in precordial leads V1-V6.  Location: Extends from the beginning of the QRS complex to the end of the T wave (includes the QRS complex. S-T segment. On rare occasions. and III. sex.  Location: Follows the S wave and the S-T segment Amplitude: 5mm or less in standard leads I. and heart rate T Wave: represents the repolarization of the ventricles. a U wave can be seen following the T wave. The U wave reflects the repolarization of the His-Purkinje fibres. II. Duration: Not usually measured . and the T wave) Duration: Varies according to age.Q-T Interval: represents the time necessary for ventricular depolarization and repolarization.

It occurs when the heart muscle is being injured by a lack of blood flow and oxygen and is also called a current of injury. This is a T wave that is taller and more pointed than the normal T wave. the ECG goes through a series of abnormalities.  Location: Extends from the end of the S wave to the beginning of the T wave Duration: Not usually measured The ECG and Myocardial Infarction During an MI. This is the hallmark abnormality of an acute MI. Hyperacute T Wave The abnormality lasts for a very short time. . The initial abnormality is called ahyperacute T wave. and then elevation of the ST segment occurs.S-T Segment: represents the end of the ventricular depolarization and the beginning of ventricular repolarization.

then the MI can be localized to a certain region of the heart. see the table below: ECG leads II. I.ST Elevation An ECG can not only tell you if an MI is present but can also show the approximate location of the heart attack. aVF Location of MI Inferior MI Anterior or Anteroseptal MI Lateral MI Coronary Artery Right Coronary Artery V1-V4 Left Anterior Descending Artery V5-V6. V2 Left Circumflex Artery Left Circumflex Artery or Right Coronary Artery Posterior MI .aVL ST depression in V1. When the ECG abnormalities mentioned above occur. III. and often which artery is involved. For example.

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