Introduction

Electrocardiography (ECG or EKG from Greek: kardia, meaning heart) is a transthoracic (across
the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected
by electrodes attached to the surface of the skin and recorded by a device external to the body. The
recording produced by thisnoninvasive procedure is termed an electrocardiogram (also ECG or EKG).
An ECG is used to measure the hearts electrical conduction system. It picks up electrical impulses
generated by the polarization and depolarization of cardiac tissue and translates into a waveform. The
waveform is then used to measure the rate and regularity of heartbeats, as well as the size and position
of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to
regulate the heart, such as apacemaker.
Most ECGs are performed for diagnostic or research purposes on human hearts, but may also be
performed on animals, usually for diagnosis of heart abnormalities or research.





Principles

The ECG device detects and amplifies the tiny electrical changes on the skin that are caused when
the heart muscle depolarizes during each heartbeat. At rest, each heart muscle cell has a negative
charge, called the membrane potential, across its cell membrane. Decreasing this negative charge toward
zero, via the influx of the positive cations, Na
+
and Ca
++
, is called depolarization, which activates the
mechanisms in the cell that cause it to contract. During each heartbeat, a healthy heart will have an
orderly progression of a wave of depolarisation that is triggered by the cells in the sinoatrial node,
spreads out through the atrium, passes through the atrioventricular node and then spreads all over
the ventricles. This is detected as tiny rises and falls in the voltage between two electrodes placed either
side of the heart, which is displayed as a wavy line either on a screen or on paper. This display indicates
the overall rhythm of the heart and weaknesses in different parts of the heart muscle.
Usually, more than two electrodes are used, and they can be combined into a number of pairs (For
example: left arm (LA), right arm (RA), and left leg (LL) electrodes form the three pairs LA+RA, LA+LL,
and RA+LL). The output from each pair is known as a lead. Each lead looks at the heart from a different
angle. Different types of ECGs can be referred to by the number of leads that are recorded, for example
3-lead, 5-lead, or 12-lead ECGs (sometimes simply "a 12-lead"). A 12-lead ECG is one in which 12
different electrical signals are recorded at approximately the same time and will often be used as a one-
off recording of an ECG, traditionally printed out as a paper copy. Three- and 5-lead ECGs tend to be
monitored continuously and viewed only on the screen of an appropriate monitoring device, for example
during an operation or whilst being transported in an ambulance. There may or may not be any
permanent record of a 3- or 5-lead ECG, depending on the equipment used.


Figure: ECG Machine








Function

An ECG produces a pattern reflecting the electrical activity of the heart and usually requires a trained
clinician to interpret it in the context of the signs and symptoms the patient presents with. It can give
information regarding the rhythm of the heart (whether or not the electrical impulse consistently arises
from the part of the heart where it should and at what rate), whether that impulse is conducted normally
throughout the heart, or whether any part of the heart is contributing more or less than expected to the
electrical activity of the heart. It can also give information regarding the balance of salts (electrolytes) in
the blood (e.g. hyperkalaemia) or even reveal problems with sodium channels within the heart muscle
cells (Brugada syndrome). Modern ECG machines often include analysis software that attempts to
interpret the pattern but the diagnoses this produces may not always be accurate.
It is one of the key tests performed when a heart attack (myocardial infarction or MI) is suspected; the
ECG can identify whether the heart muscle has been damaged in specific areas, though not all areas of
the heart are covered. The ECG cannot reliably measure the pumping ability of the heart, for which
ultrasound-based (echocardiography) or nuclear medicine tests are used. It is possible for a human or
other animal to be in cardiac arrest, but still have a normal ECG signal (a condition known as pulseless
electrical activity).



Figure: ECG Electrode Placing




Medical Uses

General symptoms indicating use of electrocardiography include:
Symptoms of myocardial infarction
Symptoms of pulmonary embolism
Cardiac murmurs
Syncope or collaps
Seizures
Perceived cardiac dysrhythmias
It is also used to assess patients with systemic disease, as well as monitoring during anesthesia and
critically ill patients.

Screening for coronary heart disease
The U.S. Preventative Services Task Force do not recommend either the ECG or any other cardiac
imaging procedure as a routine screening procedure in patients without symptoms and those at low risk
for coronary heart diseases. This is because overuse of the procedure is more likely to supply incorrect
supporting evidence for a nonexistent problem than to detect a true problem. Tests that falsely indicate
the existence of a problem are likely to lead to misdiagnosis, the recommendation of invasive procedures,
or overtreatment, and the risks associated with managing false information are usually more troublesome
than not using ECG results to make a health recommendation in low-risk individuals.
Persons employed in certain critical occupations, such as aircraft pilots, or in certain environments, such
as high altitudes, may be required to have an ECG as part of a regulatory regime.
Myocardial infarction
Characteristic changes seen on electrocardiography in myocardial infarction is included in the WHO
criteria as revised in 2000. According to these, a cardiac troponin rise accompanied by either typical
symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of
myocardial infarction.

Pulmonary embolism
In pulmonary embolism, an ECG may show signs of right heart strain or acute cor pulmonale in cases of
large PEsthe classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T
wave in lead III (S1Q3T3). This is occasionally (up to 20%) present, but may also occur in other acute
lung conditions and has, therefore, limited diagnostic value. This S1Q3T3 pattern from acute right heart
strain is termed the "McGinn-White sign" after the initial describers. The most commonly seen signs in the
ECG is sinus tachycardia, right axis deviation, and right bundle branch block. Sinus tachycardia was
however still only found in 869% of people with PE.




Design considerations

TI's new ADS1298 provides eight channels of PGA plus separate 24-bit delta-sigma ADCs, a Wilson
center terminal, the augmented Goldberger terminals and their amplifiers, provide for a full, standard 12-
lead ECG integrated analog front end. The ADS1298 reduces component count and power consumption
by up to 95 percent as compared to discrete implementations, with a power efficiency of 1 mW/channel,
while allowing customers to achieve the highest levels of diagnostic accuracy [view video]



ECG System Functionality and Evolution
Basic functions of an ECG machine include ECG waveform display, either through LCD screen or printed
paper media, and heart rhythm indication as well as simple user interface through buttons. More features,
such as patient record storage through convenient media, wireless/wired transfer and 2D/3D display on
large LCD screen with touch screen capabilities, are required in more and more ECG products. Multiple
levels of diagnostic capabilities are also assisting doctors and people without specific ECG trainings to
understand ECG patterns and their indication of a certain heart condition. After the ECG signal is
captured and digitized, it will be sent for display and analysis, which involves further signal processing.


Signal Acquisition challenges:
Measurement of the ECG signal gets challenging due to the presence of the large DC offset and various
interference signals. This potential can be up to 300mV for a typical electrode. The interference signals
include the 50-/60-Hz interference from the power supplies, motion artifacts due to patient movement,
radio frequency interference from electro-surgery equipments, defibrillation pulses, pace maker pulses,
other monitoring equipment, etc.
Depending on the end equipment, different accuracies will be needed in an ECG:
o Standard monitoring needs frequencies between 0.05-30 Hz
o Diagnostic monitoring needs frequencies from 0.05-1000 Hz
Some of the 50Hz/60Hz common mode interference can be cancelled with a high-input-impedance
instrumentation amplifier (INA), which removes the AC line noise common to both inputs. To further
reject line power noise, the signal is inverted and driven back into the patient through the right leg by an
amplifier. Only a few micro amps or less are required to achieve significant CMR improvement and stay
within the UL544 limit. In addition, 50/60Hz digital notch filters are used to reduce this interference
further.
Analog front end options:
Optimizing the power consumption and the PCB area of the analog front end is critical for portable
ECG's. Due to technological advancements, there are now several front end options:
o Using a low resolution ADC (needs all filters)
o Using a high resolution ADC (needs fewer filters)
o Using a sigma-delta ADC (needs no filters, no amplifier aside from INA, no DC offset)
o Using a sequential Vs simultaneous sampling approach.
When a low resolution (16 bit) ADC is used, the signal needs to be gained up significantly (typically 100x
- 200x) to achieve the necessary resolution. When a high resolution (24bit) sigma delta ADC is used, the
signal needs a modest gain of 4 - 5x. Hence the second gain stage and the circuitry needed to eliminate
the DC offset can be removed. This leads to an overall reduction in area and cost. Also the delta sigma
approach preserves the entire frequency content of the signal and gives abundant flexibility for digital
post processing.
With a sequential approach the individual channels creating the leads of an ECG are multiplexed to one
ADC. This way there is a definite skew between adjacent channels. With the simultaneous sampling
approach, a dedicated ADC is used for each channel and hence there is no skew introduced between
channels.


Summary

ECG is a transthoracic interpretation of the electrical activity of the heart over time captured and
externally recorded by skin electrodes.It is a noninvasive recording produced by an ECG device. In
English speaking countries, medical professionals often write EKG.
The ECG works mostly by detecting and amplifying the tiny electrical changes on the skin that are
caused when the heart muscle "depolarises" during each heart beat. At rest, each heart muscle cell
has a charge across its outer wall, or cell membrane. Reducing this charge towards zero is called
de-polarization, which activates the mechanisms in the cell that cause it to contract. During each
heartbeat a healthy heart will have an orderly progression of a wave of depolarisation that is
triggered by the cells in the sinoatrial node, spreads out through the atrium, passes through
"intrinsic conduction pathways" and then spreads all over the ventricles. This is detected as tiny
rises and falls in the voltage between two electrodes placed either side of the heart which is
displayed as a wavy line either on a screen or on paper. This display indicates the overall rhythm of
the heart and weaknesses in different parts of the heart muscle.