ELECTROCARDIOGRAM

Electrocardiogram
Human body is a volume conductor, i.e. body fluids are good conductor of electricity as it contains large amounts of electrolytes. Therefore electrical changes occurring in heart with each heart beat are conducted all over the body and can be picked up from the body surface. The record of these electrical fluctuations during cardiac cycle is called as Electrocardiogram or ECG. The instrument used to record an ECG is called as Electrocardiograph and the technique is called as Electrocardiography.

Recording Conventions
ECG is recorded on a mm square graph paper, moving at a speed of 25mm/sec. X – axis represents time, therefore 1mm = 0.04sec. Y – axis represents voltage, therefore 1mm = 0.1mV. Any deflection of record above the baseline is regarded as positive deflection. It occurs when active electrode becomes positive relative to indifferent electrode and denotes spread of excitation wave i.e. depolarization wave towards the electrode. Any deflection of record below baseline is regarded as negative deflection. It occurs when active electrode becomes negative relative to indifferent electrode and denotes spread of excitation wave i.e. depolarization wave away from the electrode. No deflection from baseline means isoelectric line or isoelectric segment.

Waves of ECG
P, Q, R, S, T, U.

P - wave :

•Duration – 0.1 sec, directed upwards and rounded/pointed. •It is due to atrial depolarization and represents spread of impulse from SA node to atrial muscles. •Peaks corresponding with invasion of AV node. •Height is 0.5mV, represents functional activity of atrial muscles. •

PR segment :

•Following P-wave there is brief isoelectric period of 0.04 sec.

QRS complex :

•Due to ventricular depolarization. •Completed just before opening of semilunar valve. •Atrial repolarisation activity merges with QRS complex. •

Q wave :

•Small negative deflection of height less than 0.2mV and duration less than 0.04s. •Beginning of Q-wave represents the invasion of mid-portion of IV septum.

R - wave :

•Prominent positive wave. •Upstroke coincide with onset of ventricular systole. •Represents excitation process suddenly invading both ventricles i.e. interventricular septum and larger part of both ventricles. •Height is directly proportional to functional activity of ventricles. •

S - wave :

•Negative deflection which follows R-wave. •Represents excitation of more basal parts of ventricles. • Duration of QRS complex 0.08 to 0.12 sec and height of 1.5-2 mV.

ST segment :

•Isoelectric period from end of S-wave and beginning of T-wave. •Duration 0.04-0.08 sec. •

T - wave :

•Rounded positive deflection of duration of 0.27 sec and 0.5 mV in height. •Represents ventricular repolarisation. •End of T-wave coincides with closure of semilunar valves.

Isoelectric period :
•Following T-wave small isoelectric period – 0.04 sec.

U - wave :
•Rarely seen, positive, small, round wave. •0.08 sec in duration and 0.2 mV in height. •Due to slow repolarization of papillary muscles. •

PR Interval :

• •Interval from beginning of P-wave till beginning of Q/R wave. •Represents atrial depolarization and conduction time of Bundle of His. •Normal duration 0.13 - 0.16 sec. •

QT interval :

•Interval from beginning of Q and end of T-wave. •Duration 0.4 sec. •Represents ventricular depolarization and repolarization.

ST interval :
• •End of S wave to end of T wave. •Normally 0.32 sec. •Represents ventricular repolarization. •

J point :

• •Point between S wave and ST segment. •Point of no electrical activity. •

Procedure of recording ECG
Two methods are employed : 1.Unipolar method in which ECG is recorded using one active electrode. 2.Bipolar recording in which ECG is recorded using two active electrodes.

Unipolar Method :

In a volume conductor, the sum of potentials at ends of an equilateral triangle with current source at its centre is zero at all times. A similar triangle can be approximated in our body by placing electrodes at RA, LA and LF, where heart in centre acts as current source

1 . Precordial leads of Wilson : V1 – 4th intercostal space to right of sternum V2 – 4th intercostal space to left of sternum V3 – midway between V2 and V4 V4 – 5th intercostal space in mid-clavicular line V5 – 5th intercostal space in anterior axillary line V6 – 5th intercostal space in mid-axillary line 1.

2 . Unipolar limb leads : VL – left arm VF – left foot VR – right arm Characteristics : 1.V1 and V2 reflect right ventricular activity and QRS deflection is negative 2.V3 and V4 reflect activity of both ventricles at interventricular septum activity and is biphasic 3.V5 and V6 reflect left ventricular activity mainly and is positive P-wave is always positive as wave travels from SA node (posteriorly) to AV node (anteriorly) T wave mailnly follows main direction of QRS complex 1.VF reflects activity of inferior surface of heart formed by both ventricles – biphasic QRS complex 2.VL reflects electrical activity of left outer surface of heart – predominantly positive QRS complex 3.VR reflects electrical activity of cavity of ventricles thus all waves P QRS and T waves are all negative 7.

Augmented limb leads :
These are unipolar leads with slight modification in recording technique. One limb is connected to positive terminal of ECG and other 2 limbs connected through electrical resistance to negative of ECG machine. This arrangement increases size of potentials by 50% without any change in configuration Vector of augmented limb leads = 3/2 vector of unaugmented limb lead These are aVL, aVF, aVR.

Bipolar Recording :
ECG is recorded using two active electrodes therefore the deflection recorded here at any movement represents algebraic sum of two constituent limb leads. Bipolar leads are: Lead I : Records difference in potentials between RA and LA (LA positive) and QRS similar as aVL. Lead II : Records difference in potentials between RA and LF (LF positive) and QRS deflection same as aVF. Lead III : records difference in potentials between LA and LF (LF positive) and QRS is similar to aVF.

Eithoven ’ s Law :
Lead II = Lead I + Lead III = (VL-VR) + (VF-VL) = VF-VR

Importance of 12 Lead ECG
It is necessary to have 12 lead ECG because leads I, II and III, aVL, aVF and aVR reflects depolarization of heart from frontal plane and V1 to V6, reflect electrical activation of heart from horizontal plane. Thus, it gives a 2D picture of 3D electrical activity of myocardium.

STRESS TEST

Stress Testing
A cardiac stress test is a medical test that indirectly reflects arterial blood flow to the heart during physical exercise. When compared to blood flow during rest, the test reflects imbalances of blood flow to the heart's left ventricular muscle tissue – the part of the heart that performs the greatest amount of work pumping blood.

Procedure :
The patient either walks on a treadmill or is given an intravenous(IV) medication that simulates exercise while connected to an electrocardiogram(ECG) machine used to record a 12-lead ECG. The level of exercise is increased in 3-minute stages of progressively increased grade (% incline) and speed (mph, km/h, etc). The patient's symptoms and blood pressure response are repeatedly checked. Some patients with abnormal resting ECGs or those who are unable to walk safely can be "exercised" pharmacologically instead of by walking on a treadmill. The patient will typically receive a pharmaceutical such as dipyridamole or adenosine or dobutamine (which stimulates heart rate and pumping force) while a cardiologist or physician assistant reviews the ECG tracing and checks blood pressure periodically.

Bruce Protocol :
A protocol for exercise stress testing of cardiac patients developed by Robert A. Bruce. Before the development of the Bruce Protocol there was no safe, standardized protocol that could be used to monitor cardiac function in exercising patients.

Stage 1 2 3 4 5

Min 3 6 9 12 15

% 10 12 14 16 18

MPH 1.7 2.5 3.4 4.2 5

METS 4.7 7 10.1 12.9 15

How does a Regular Stress Test Work?
Patients with coronary artery blockages may have minimal symptoms and an unremarkable or unchanged ECG while at rest. However, symptoms and signs of heart disease may become unmasked by exposing the heart to the stress of exercise. During exercise, healthy coronary arteries dilate more than an artery that has a blockage. This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery. In contrast, narrowed arteries end up supplying reduced flow to it's area of distribution. This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and the ECG may produce characteristic abnormalities.

When is a Regular Stress Test ordered?
ØPatients with symptoms or signs that are suggestive of coronary artery diseases (CAD). Ø ØPatients with significant risk factors for CAD. Ø ØTo evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath. Ø ØTo evaluate blood pressure response to exercise in patients with borderline hypertension. Ø ØTo look for exercise-induced serious irregular heart beats. Ø

What is the reliability of a Regular Stress Test?
If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% of patients with coronary artery disease. The accuracy is lower (about 50%) when patients have narrowing in a single coronary artery or higher (greater than 80%) when all three major arteries are involved. Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease).

Contraindications:
• ØAcute myocardial infarction within 48 hrs ØUnstable angina not yet stabilized with medical therapy ØUncontrolled arrhythmia ØSymptomatic severe aortic stenosis ØAortic dissection ØPulmonary embolism ØPericarditis • •

Risks:

ØPalpitation ØChest pain ØShortness of breath ØHeadache ØNausea ØFatigue ØAdenosine and dipyridamole can cause mild drug-induced hypotension. Ø

Limitations:
Ø

ØStress tests do not detect atheroma or vulnerable plaque. Ø ØIt requires high-grade stenosis to indicate heart attack risk. Ø ØLike all tests, stress testing has problems with both falsely positive and falsely negative results.

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